Failure to De-escalate Disruptive Patient Behavior

In the following case, the patient and his wife were removed from the ED for using profanity and issuing threats. The patient may not have become disruptive if de-escalation strategies had been used. Consider what could have been done differently.

Although the treatment in the following case took place in an ED, the de-escalation strategies presented can be used in multiple healthcare settings.

Allegation

Delayed diagnosis of epidural abscess resulted in paraplegia.

Case File

On a Monday, a man presented to the ED with severe lower back pain. After an unsuccessful trial of oxycodone, he was given IV pain medications, which brought his pain down to a manageable level. He was discharged with a diagnosis of muscle strain, given a prescription for oxycodone and muscle relaxants, and instructed to follow up with his PCP.

On Tuesday morning, the patient returned to the ED via ambulance. He reported 10/10 back pain with no relief from the medications prescribed the day before. A different ED physician ordered an MRI, but the patient was unable to lie still because of the pain. He was returned to the waiting room. The ED physician ordered oral oxycodone, with the plan to try oxycodone first, then try stronger pain medications if the oxycodone did not achieve the pain relief necessary to allow the MRI to go forward. A nurse brought the patient oxycodone, explaining it would relieve his pain and allow him to lie flat for an MRI. Very loudly and profanely, the patient informed the nurse that he had tried oxycodone, and it didn’t work. He demanded immediate administration of the same intravenous pain medications he had been given the previous day.

The nurse informed the patient that she could not administer what the physician did not order. She gave the patient and his wife a warning about their behavior, telling them they would be removed from the premises if they did not calm down. In response, the patient’s disruptive behavior escalated. Between bouts of swearing and moaning in pain, he demanded to see a physician, refused to leave without getting an MRI, and threatened to hire a lawyer. His wife loudly made vague threats about hurting people if her husband didn’t get the pain relief he needed. The security guard, at this point, determined the patient and his wife met the criteria for being removed from the premises. He wheeled the patient out to the parking lot.

One week later, the patient got an MRI, which showed marked spinal cord compression due to an epidural abscess. Emergency surgery was performed, but the patient sustained permanent neurological deficits. He sued every person on his healthcare team.

Discussion

Viewed in retrospect, the cause of the patient’s mounting frustration, agitation, and anger is understandable: he was in significant pain and he had achieved relief the previous day with IV medications, but he continued to be offered oxycodone, which was not working. While threats of harm and profanity are not excused, the entire episode might have been avoided if the ED nurse and/or security guard had used de-escalation techniques and advocated on behalf of the patient, instead of dismissing his demands for intravenous pain medication and removing him from the ED.

The ED physician also should have reviewed the patient’s recent history, discussed her pain management strategy with the patient, and considered an alternative to oxycodone, based on the circumstances. Delivering adequate pain relief was the key to avoiding a devastating injury and lawsuit—experts surmised that the epidural abscess would have been visible had the MRI been successful, and that the permanent nerve damage would have been avoided had he undergone surgery earlier.

Risk Reduction Strategies: Disruptive Behavior Mitigation & Response

Violent individuals do not “just snap.”¹ Disruptive patient behavior can be avoided, mitigated, and appropriately managed. It requires strong disruptive patient and workplace violence policies and procedures with flexibility to allow clinicians and staff to individualize the response depending on the potentiality of danger. Individualizing a response requires appropriate training; therefore, it is important to provide the necessary tools to clinicians and staff to protect their safety while also satisfying patient healthcare needs.

Clinicians and Staff

Consider the following strategies:^2,3,4,5

• Mitigate personal safety risks when interacting with a patient (or patient’s family member) who has a history of violence, including:
  • Determine the best plan for potentially violent patients on the schedule for the day during the daily huddle or during a huddle specifically devoted to the particular patient.
  • Share information about a patient’s potential for disruptive behavior with members of the healthcare team who do not have access to EHR warnings or huddles.
  • Request an additional staff member to be present during encounters.
  • Involve a social worker, who can help de-escalate, so the clinician can focus on the patient’s medical issues.
  • Remove potential weapons from the examination room (e.g., lamps, fire extinguishers, etc.).
  • Search the patient for items that may be used as a weapon.
  • Inventory and secure personal property that could be used as a weapon (e.g., an insured was attacked with a bicycle seat).
  • Treat known aggressors in relatively open, easily accessible areas that still reasonably maintain privacy (e.g., rooms with removable partitions).
  • If an easily accessible area is not available, position yourself between the patient and the door.
  • Maintain two arms’ length of space between you and the patient.
  • Reinforce behavioral expectations with the patient.
• Avoid triggering disruptive behavior, particularly when the patient is exhibiting signs of imminent violence. (See “Recognizing the Triggers of Disruptive Patient Behavior”)
• Maintain your composure if a patient becomes disruptive.
  • Know your own triggers that may escalate the tension between you and the patient.
  • When you are triggered, tell the patient you are going to leave and return in five minutes, and then take a break. Have a plan before you resume the encounter.
  • Use “I” messaging to communicate how you feel, why you feel that way, and how the individual can change to remedy the situation. For example, say, “I feel frustrated when you yell at me because I am having a hard time understanding what you are trying to tell me. I would like you to stop yelling.”
  • Discover what has triggered a patient’s disruptive behavior and how the individual wants the situation resolved.
  • Focus on what is causing the undesirable behavior, not the behavior itself.
  • Ask open-ended questions (questions that cannot be answered with a “yes” or “no” response, and often begin with words like “How,” “When,” "What”) that can facilitate your understanding of the individual’s feelings and intentions, for example, ask: “What is your major concern right now?” “How can I help?” “What can I do?”
  • Effectively use silence, which can encourage the patient to provide more information and can allow the individual to calm down.
  • Use short, concise sentences, and simple vocabulary. Complex sentences can increase agitation.
• Use active listening techniques, for example:
  • Paraphrase and summarize, using the individual’s own terminology, to ensure that you understand what the individual is trying to communicate and to show you are listening.
  • Repeat back the individual’s major concerns, for example, say “You think intravenous pain medications will help you lie still for the MRI.”
  • Use “minimal encouragers” (words, phrases and gestures that encourage the patient to continue and show you are listening); for example, use “OK,” “I see,” “go on.”
  • Avoid telling the patient that you understand if there is no way you would understand.
• Suspend judgment of the individual’s behavior.
  • Avoid questions that begin with “why,” which can be perceived as judgmental.
  • Put yourself in the patient’s shoes to gain perspective on the patient’s behavior.
• Do not attempt to control behavior that does not impact safety.
• Use body language that can reduce feelings of confrontation (e.g., maintain an open posture and stand at an angle to the individual).
• Find aspects of the individual’s position with which you can agree.
• Express optimism by using positive language and avoiding words like “but,” “can’t,” and “don’t.”
• Offer options for reducing agitation (e.g., “We can give you some medication to help you to feel more relaxed.” “Would you be more comfortable in an examination room?” “Can we start this conversation over? I feel like we got off on the wrong foot.”)
  • Reach an agreement with the patient about how the situation can be resolved, then follow through.
• If de-escalation strategies are not effective and the patient is threatening your safety, excuse yourself, leave the room or move away from the patient, and then get help.
  • Do not notify the individual that you are calling in help, as this may further escalate his or her agitation.
  • When appropriate, evacuate other individuals who are endangered.
• After de-escalation, if the patient does not pose a safety risk, use rehabilitation strategies to direct the individual’s behavior in the future.
  • Explain behavioral expectations and issue behavioral warnings. (See HealthPOiNT’s “Patient Warning Letter #2” for an example)
    • Involve security, a practice manager, and/or an administrator when appropriate.
    • Present the patient with a behavior agreement. (See the Regions Hospital “Patient and Care Team Partnership Agreement” as an example.)
    • Start the termination process if the patient refuses to engage in behavior modification.
  • At hand-off, pass on information about incidents of disruptive behavior or potential safety risks posed by the patient.
  • Document disruptive behavior and behavioral expectations for the future.
  • Create (or request the creation of ) an EHR disruptive patient flag (see the “Electronic Health Record: Disruptive Patient Flags“ sidebar).
  • Report the incident using a process that protects the report from discovery in litigation to the greatest extent possible.
  • Seek assistance for personal trauma associated with a disruptive patient encounter.
  • Practice de-escalation with colleagues.

Operations

Consider the following strategies:^2,3,4,5

• Put workforce violence/disruptive patient behavior policies and procedures in place.

Ensure that patient behavior precautions and interventions can be entered into the EHR in a manner that will alert clinicians and staff to the potential necessity of activating disruptive/violent patient strategies (see the “Electronic Health Record: Disruptive Patient Flags“ sidebar).

• Train clinicians and staff to mitigate and respond to disruptive patient behavior, including the management of their own stress and frustration that may arise during the encounter.
• Create behavioral response teams.
• Put systems in place that facilitate workplace violence reporting by victims and bystanders.
  • Create an environment in which victims do not fear reprisal for reporting violence.
  • Review each incident of workplace violence.
  • Debrief with involved individuals following an incident.
  • Involve victims in the creation of safety risk reduction strategies based on lessons learned from the victim’s experience.
• Report incidents to leadership, security, law enforcement, and state authorities as necessary, pursuant to workplace violence regulations and guidelines.
• Provide accessible, effective support for all clinicians and staff experiencing workplace violence.
• Make the workplace safer.
  • “Nudge” (short, personalized recommendations with a clear call-to-action) patient behavior in a positive direction. For example, one health system uses signs reminding visitors to: “Please take responsibility for the energy you bring into this space ...your behaviors matter. Our patients and caregivers matter. Take a slow, deep breath and make sure your energy is in check before entering.”⁶
  • Post emergency contact numbers (e.g., security and police) near the reception desk, nurses’ station, or other central locations where clinicians and staff congregate.
  • Use standardized emergency codes over the facility intercom to indicate the presence of a violent or combative individual (e.g., code gray).
  • Prohibit clinicians and staff from working alone, particularly at night.
  • As necessary, install security cameras and security alarms, simplify exit routes, install metal detectors and barrier protections, install panic buttons in strategic locations, improve lighting, and control access in and out of facilities.
  • Mitigate the risk of patients using items in your facility as weapons (e.g., insureds have been attacked with various items patients found in treatment areas, including a pipe that was unscrewed from a toilet, a fire extinguisher, and an IV pole).
  • Mitigate the risk of areas in your facility providing an opportunity for assault or hostage-taking, such as empty hallways, unlocked storage areas, or separated work areas.
• Conduct risk assessments regularly to evaluate preparedness for workplace violence.

Electronic Health Record: Disruptive Patient Flags

Although workplace safety is imperative, bias and discrimination may result from identifying a patient as violent or disruptive in his or her medical record. As an alternative to a general flag on the record, identifying behavior precautions and interventions can avoid bias (e.g., a brief description of the safety risk and description of appropriate actions to ensure safety), while serving the purpose of alerting clinicians and staff to the potential necessity of activating disruptive behavior mitigation measures. Consider the following strategies:¹

• Enable click-through from the flag to a more detailed account of the basis for the flag and individualized strategies for mitigating and managing disruptive behavior.
  • Put a process in place for creating, approving, reviewing, and updating flags. Some questions to consider in formulating or adjusting a plan include:
    • Behavior management and risk mitigation strategies that have been effective
    • Events, situations, or conditions that might trigger the patient
    • Behavioral changes that may indicate escalating or diminishing risk
    • Significant life or healthcare events
    • Key individuals who can provide insight into the patient’s behavior
  • Provide training to clinicians and staff on how to create and respond to the flags, and how to identify and manage bias towards disruptive patients.

A more in-depth discussion of disruptive patient record flag use can be found in the U.S. Veterans Health Administration’s Implementing Multidisciplinary Behavioral Threat Assessment and Management Practice in Health Care: Disruptive Behavior Committee (DBC) Guidebook starting at page 69.

Additional Resources

OSHA: Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers

Voluntary guidelines for preventing workplace violence, which include recommendations for developing policies and procedures to eliminate or reduce workplace violence in a range of healthcare and social service settings

The Joint Commission: Workplace Violence Prevention Resources

A collection of The Joint Commission publications on workplace violence, including links to the Workplace Violence Prevention Standards, which took effect January 1, 2022, for accredited hospitals and critical access hospitals, and the Workplace Violence Prevention Compendium of Resources to Support Joint Commission Accredited Hospitals in Implementation of New and Revised Standards, which provides resources that can be used to help accredited organizations meet the new workplace violence requirements.

Minnesota Department of Health: Prevention of Violence in Health Care Toolkit

Resources for facilities seeking to establish a violence prevention program or improve their current program, containing sample policies and procedures, articles, and staff and leader education tools

ProAssurance: Violence in Healthcare

A “2 Minutes: What’s the Risk?” video introducing strategies to prevent workplace violence

Richmond JS, et al.: Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

Foundations for appropriate training for de-escalation and intervention guidelines, using the “¹⁰ domains of de-escalation”

U.S. Veterans Health Administration: Implementing Multidisciplinary Behavioral Threat Assessment and Management Practice in Health Care: Disruptive Behavior Committee (DBC) Guidebook

Guidebook describing primary violence prevention strategies, secondary prevention strategies that respond to violence as it unfolds, and tertiary prevention strategies for managing the aftermath of violence

American Nurses Association: Reporting Incidents of Workplace Violence

A multifaceted strategy to combat workplace violence, including promoting and instilling a culture of zero tolerance toward workplace violence

Agency for Healthcare Research and Quality: Daily Huddle Component Kit

Strategies and rationales for daily huddles involving members of the healthcare team

References

1. Workplace Violence Prevention Program, Office of Mental Health and Suicide Prevention, U.S. Veterans Health Administration (VHA). Implementing Multidisciplinary Behavioral Threat Assessment and Management Practice in Health Care: Disruptive Behavior Committee (DBC) Guidebook. February 2021. [PDF]

2. The Joint Commission. “Sentinel Event Alert 59: Physical and Verbal Violence Against Health Care Workers.” Revised June 2021.

3. Janet S. Richmond, 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. 2012; 13(1); 17-25. DOI: 10.5811/westjem.2011.9.6864.

4. Isolde M. Busch. “The Role of Institution-Based Peer Support for Health Care Workers Emotionally Affected by Workplace Violence.” Joint Commission Journal on Quality and Patient Safety. 2021; 47(3): 146–156. DOI: 10.1016/j.jcjq.2020.11.005.

5. Tochi Iroku-Malize, Maureen Grissom. “The Agitated Patient: Steps to Take, How to Stay Safe.” The Journal of Family Practice. 2018; 67(3): 136-147. PMID: 29509816

6. Christine Porath, Adrienne Boissy. “Frustrated Patients Are Making Health Care Workers’ Jobs Even Harder.” Harvard Business Review. May 14, 2021.