Substance Abuse or Intoxicated Patients

In the context of the present opioid epidemic, drug users often seek treatment in an emergency department. As most drugs are used and abused illegally, this again blurs the line between criminal behavior and treatment of patients.  In most cases, patients who present to the ER who are intoxicated or under the influence of illegal substances are seeking medical treatment and should therefore receive all protections that being a patient provides.  That being said, alcohol and substance abusers do present an increased risk for violence against staff.[23] Though nearly any addictive drug can cause bizarre behavior, some drugs are especially prone to causing violence and aggression.  Patients who are under the influence of the drugs listed below should be handled with extreme caution:

  • Bath Salts is a term used to describe a number of substances that are made synthetically and produce effects similar to illegal drugs. Bath Salts are illegal in 41 states but can be sold and purchased legally in others.  They can cause panic attacks, paranoia, hallucinations, violence and suicidal behavior.
  • Cocaine is an illegal, addictive drug that has stimulant properties. Cocaine affects the nervous system and can make users feel euphoric. It can also cause paranoia, anxiety, tremors and convulsions. Large amounts or frequent use of cocaine can cause hallucinations, paranoid delusions, psychosis and depression.
  • Anabolic steroids can cause psychiatric effects, especially aggression. These drugs can also cause mania, psychosis, mood swings, suicidal thoughts and violent behavior
  • LSD use is characterized by hallucinations and the inability to think clearly. While users can have positive reactions to LSD, negative reactions can include paranoia, delusions, anxiety and psychosis[26]
Risk Factors

There are general risk factors to consider as well as impending signs of possible violent behavior to be aware of when determining how to best manage a patient.  General risk factors include younger age, male gender, history of violence, use of weapons, threats to harm, substance abuse and a history of physical abuse.  Younger age and male gender are fairly easy to identify by security staff.  However, there may not be easy access to patient history information.  It is critical that all healthcare team members, including security officers, share whatever information about the patient’s current condition is available and that they can recognize the signs of impending violence.  These signs include flushing of skin, dilated pupils, shallow rapid respirations, excessive perspiration, restlessness and pacing, impulsivity and intimidating physical behavior such as clenching fists and are signs that an act of violence is imminent.[24] [27]  Immediate steps must be taken to ensure the safety of the patient and the staff to avoid escalation to a level requiring the use of handcuffs.

Response

While none of these medical issues or violence risk factors guarantee an individual will be violent toward staff, security officers should be much more alert to the increased potential for violence or aggression.  There is always a cause for aggression, usually a combination of intrinsic and extrinsic factors.  A good starting point is to assume that any aggression indicates a patient’s distress, or an attempt to communicate an unmet need by someone whose coping abilities are failing. The person wants something, wants to do something or is afraid of something.[28]  Care givers and security officers should be proactive in managing these patients while trying to identify and meet these needs.  Proactive management techniques could include extra comfort items such as food, drink and blankets if appropriate, dimming the lights and decreasing stimuli from the environment, providing earlier opportunities for calming medication or earlier consideration for use of physical or chemical therapeutic restraints if less aggressive techniques are failing.  As was mentioned earlier, handcuffs should be used on patients in only the direst circumstances when lives have been placed at risk.  It is rare that a situation, if managed proactively early on, should escalate to the point of imminent danger where the use of handcuffs may be necessary.

BEST PRACTICES

Prevention

The most critical component of a management strategy for the use of handcuffs in the healthcare environment is the strategy to prevent their use in the first place.  The first tool is de-escalation training for staff.  There are many programs available such as the Crisis Prevention Institute (CPI),[27]Verbal Judo,[28] Non-Abusive Psychological and Physical Intervention (NAPPI)[30], Management of Aggressive Behavior (MOAB),[31]  and the Ten Domains of De-escalation.[32] These programs teach staff to recognize and respond to violence cues to help patients regain control.  They also teach staff how not to inadvertently escalate situations as well as give staff increased confidence in dealing with agitated people.  For this reason, training should not be limited to security or behavioral health staff, but instead offered to all staff members who might encounter an upset person or family member.[27]

It is also critical to foster a team environment between nursing, security and administration.  Recognizing, preventing and responding to violence is the responsibility of everyone involved with the care of a patient.   Security teams should understand the medical protocols and medical teams should understand the security protocols.[33] Care givers and security staff must work together and be supported by hospital administration that patients will not be permitted to be abusive toward staff.[34]

Hospitals should have mechanisms in place to alert staff if a patient has previously been violent in the facility.  This flag can be part of the medical record, registration process or security system as long as it quickly informs staff that the patient has demonstrated a violent tendency in a previous encounter.[35]  If a patient is pre-identified as having acted out, actions can be taken proactively such as involving security early or clearing the patient’s room of anything that could be used as a weapon.

The last key component to prevention is a strong workplace violence program.  OSHA requires it and facilities will have more success mitigating violence if employees feel supported and safe.  The program should encourage reporting incidents including verbal abuse and near misses.   It must also provide appropriate follow-up support to victims and others affected by workplace violence.  Incidents of violence must be reviewed to determine contributing factors and opportunities for intervention and improvement.  There are many resources available to assist in developing healthcare workplace violence prevention programs, the most comprehensive being OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.[2]

Strong Response to Criminal and Abusive Behavior

It is also important for healthcare organizations to have strong policies and practices against criminal and abusive behavior.  Simply being a patient or under the influence of drugs or alcohol does not excuse abusive behavior.   When behavior is criminal and conducted with mal-intent, patients should be charged and prosecuted.[35]  Additionally, when crimes are committed on property, especially those that involve threats or violence, it is important for employees to see security officers using the tools available to them such as handcuffs to detain criminals and have them removed.  Staff must feel that their safety is important to administration and that abusive or criminal behavioral will not be tolerated.

[26] https://drugabuse.com/what-drugs-cause-the-most-insane-behavior/

[27] Crisis Prevention Institute https://www.crisisprevention.com

[28] Harwood, RH.  “How to deal with violent and aggressive patients in acute medical settings.” Journal of the Royal College of Physicians of Edinburgh, vol. 47, iss. 2, June 2017.  doi: 10.4997/JrCPe.2017.218

[29] Verbal Judo http://verbaljudo.com/

[30] Non-Abusive Psychological and Physical Intervention   https://nappi-training.com/

[31] Management of Aggressive Behavior (MOAB)  https://www.moabtraining.com/

[32] Richmond, Janet et. al.  “Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.” Western Journal of Emergency Medicine, vol. 13, iss. 1, pp. 17-25, February 2012.  doi:  10.5811/westjem.2011.9.6864

[33] Cloney, Lee.  “Responding to Violence in Healthcare.” Security Management.  June 26, 2017.  https://sm.asisonline.org/Pages/Responding-to-Violence-in-Healthcare.aspx

[34] The Joint Commission. “Preventing violence in the health care setting.” Sentinel Event Alert, iss. 45, June 3, 2010. Retrieved September 9, 2018 from https://www.jointcommission.org/assets/1/18/sea_45.pdf

[35] Vogel, Lauren.  “Abusive patients: Is it time for accountability?” Canadian Medical Association Journal, vol. 188, iss. 11, pp. E241–E242, August 9, 2016.  doi:  10.1503/cmaj.109-5266

[36] Weber, Ryan.  “Patients are people first.”  Security Management, February 2018.  Retrieved September 1, 2018 from https://sm.asisonline.org/Pages/Patients-Are-People-First.aspx