Violence towards health care workers is unfortunately common.
40% of all violence-related claims in BC are submitted by health care workers despite only making up 5% of the workforce.

• Up to 50% of health care workers will experience violence during their careers.
• Violence and agitation = behaviours &/or actions that can cause harm or injury to another person.
• The manifestations of violence and agitation are diverse and depend on a combination of extrinsic (environment, provider attitudes, and behaviour) and intrinsic (medical conditions, personality characteristics, mental distress) factors.

High-risk factors

—associated with agitation and violence include:

• • Alcohol or drug use disorders.
  • Young age.
  • Male.
  • Personal history of violence.
  • Chronic pain.
  • Poor communication among staff.
  • Lack of privacy.

Signs of impending violence

• • Angry demeanor.
  • Loud/aggressive speech.
  • Provocative behaviour.
  • Tense posturing.
  • Pacing or frequently changing body position.

☎ Call the police

—immediately if:

• • Acts destructively (ie. hitting things or destroying equipment).
  • Is armed,
  • Makes verbal or physical threats that you do not have the resources (security) to contain,

Created and adapted from references 2, 4, 5.

• If an underlying psychiatric or medical condition has been identified and requires inpatient management.
• Patients should be observed post-sedation for further assessment and monitoring.
  • Degree of sedation (Glasgow coma scale).
  • Vitals.
  • Pupils.
  • Blood glucose.
  • ECG rhythm.
  • Adverse effects of antipsychotic meds: Neuroleptic Malignant Syndrome (NMS), extrapyramidal symptoms, hyperprolactinemia, postural hypotension, serotonin syndrome (link between SGAs and serotonin syndrome).

Observe patients in alcohol withdrawal

1/20 people with withdrawal symptoms may experience delirium tremens (DT)—increased risk of heart attack, stroke, or death.

Level of Observation

—consider patient’s:

• Current mental state.
• Risk assessment.
• Medications and side effects.

Views of the patient:

• • Low-level intermittent observation = every 30-60 mins.
  • High-level intermittent observation = every 15-30 mins.
    • Use in patients where there is no immediate risk, but you suspect they could become violent or aggressive.
  • Continuous observation: if patient presents immediate threat.
  • Multiprofessional continuous observation: highest risk patients. Need to be within eyesight of 2 or 3 staff.

• Consider discharge in patients where the underlying concern has resolved.

1. Provincial Quality, Health & Safety Standards and Guidelines for Secure Rooms in Designated Mental Health Facilities under the B.C. Mental Health Act.
   Ministry of Health — Province of British Columbia

   
   

2. The Patient Safety Education Program – Canada (PSEP – Canada) Curriculum. Mental Health Care: Diminishing Violence and Aggressive Behaviour.
   Emanuel, L., Taylor, L., Hain, A., Combes, J.R., et al.,
   Walton M, eds.
   © PSEP-Canada, 2013.

    

   
   

3. Trauma-Informed Practice Guide.
   Arthur, E., Seymour, A., Dartnall, M. et al.,
   BC Provincial Mental Health and Substance Use Planning Council (May 2013).
   

   
   

4. GUIDELINES: CODE WHITE RESPONSE. A Component of Prevention and Management of Aggressive Behaviour in Healthcare.
   Albach D. ,  Armstrong J. , Bullock L., et all.
   Health Association of BC. | Work Safe BC | Occupational Health and Safety Agency for Healthcare in BC.
   www.saswh.ca

   
   

5. Preventing Violence in Health Care: Five Steps to an Effective Program.
   Work Safe BC (Dec 2005).
   worksafebc.com/

    

   
   

1. Use of Antipsychotics And/or Benzodiazepines as Rapid Tranquilization in In-patients of Mental Facilities and Emergency Departments.
   Canadian Agency for Drugs and Technologies in Health. CADTH. 2015.

   
   

2. Managing aggressive and violent patients.
   Fulde, G., Preisz, P.,
   Australian Prescriber. 2011;34(4):116-8.

   
   

3. How to deal with violent and aggressive patients in acute medical settings.
   Harwood, R.H. 
   Physicians Edinb. (2017;47(2)).

   
   

4. Assessment and emergency management of the acutely agitated or violent adult.
   Moore, G., Pfaff, J.A.
   UpToDate. 2019.
   www.uptodate.com

   
   

5. Violence and aggression: Short-term management in mental health, health and community settings.
   National Collaborating Centre for Mental Health (UK).
   The British Psychological Society.(2015).

   
   

6. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project Beta Psychopharmacology Workgroup.
   Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D.
   West J Emerg Med. 2012;(1):26-34.