Saturday, May 19, 2018

Wish I Had Said Some More About The Violence......

I shot a video for the 100 Miles 100 Stories charity yesterday.  Their mission is raise awareness for violence against healthcare workers.  They found me through a nurse that I used to work with who sustained a traumatic brain injury when she was assaulted in an emergency department.  The sequelae of that injury ended her career in nursing. The focus of this charity is to raise public awareness of the problem and hopefully find some solutions.  As I have posted on this blog many times, these incidents are generally preventable, but it requires both expertise and a major revision of the systems that most health professional work in every day. I had a meeting two weeks ago on the comments I could make in this area and the interview questions were based on that meeting.  I don't have a transcript or tape and the final version will be edited.  This is my recollection of what happened:

Q:  Tell us about your experience.

A:  I have been a psychiatrist for 32 years and about 22 of those years have been in acute care psychiatric settings at what is now called Regions Hospital.  It used to be St. Paul-Ramsey Medical Center before it was acquired by HealthPartners.  For about 8 of those years a neurologist and I ran a clinic for Alzheimer's Disease and other dementias.

Q:  What kind of psychiatric diagnoses did you see?

A:  Bipolar disorder, major depression, schizophrenia, schizoaffective disorder, personality disorders with a significant overlay of alcohol and substance use.

Q:  Were you ever assaulted?

A:  I was punched three times but there was no serious injury.  Threatening behavior was more a problem.  There were homicidal threats that had the most significant impact on me long term.  As an example, I started to be more conscious of home security and have home security and close circuit TV cameras installed.

The interview is biased on a personal point of view.  If I had been thinking more I could have mentioned what I had seen.  One psychiatrist punched and knocked out.  Another psychiatrist beaten up with a resulting career ending traumatic brain injury. Various injuries to nursing staff and nursing assistants who have the majority of contact with agitated and potentially aggressive patients.  One evening I was talking with nursing staff behind a window that we believed was shatterproof glass. Without warning the window exploded as a heavy chair sailed through it.  Being one step away from very serious injuries and deaths in many situations, but the downside is that may have seemed like an embellishment so I left it out.

Q:  Why do you think it is happening?

There are several reasons.  The lengths of stays in psychiatric units these days is either too long or too short.  People are discharged in 3 or 4 days or they are waiting there for weeks or months to go to a state hospital bed because they are committed.  Acute care inpatient units are not set up to accommodate people staying there that long.  When I interview people have been discharged from inpatients units they typically tell me that they were sitting around watching TV until they could convince somebody that they are not suicidal.

If we consider a person who is experiencing auditory hallucinations who goes to the emergency department for help they might not get admitted for that problem.  They will probably be told to go to an outpatient appointment in a month or two.  In the meantime - they are untreated and that symptoms gets worse.  If they come into the emergency department again, they may angry the second time.  The current system of care has a large circulating pool of partially stabilized or unstable patients that go between the ED, homelessness and homeless shelters, and acute care hospitals.

I should have used the term dangerousness.  I have written about it countless times on this blog but not in the interview.  Dangerousness is essentially the only way that people get admitted to inpatient psychiatric units any more.  That arbitrary business decision rations access to care for people who have also experienced rationing at a both the community level with less housing and at the state hospital level with a marked reduction is state hospital beds.

Q:  What do you think can be done about it?

Changes have to occur at two levels.  Government and business administrators have to open up access to more beds in both state hospitals and community housing.  There has has to be more enlightened management of those beds.  At the service provider level there needs to be a team approach to the problem.  Frequently if there is an assault related injury, there is a lot of silence and nobody talks about it.  Some splitting can occur and some disciplines may think that it can't happen to them.  The victims may blame themselves and become very isolated.  Administrators at every level need to support clinical teams to address this problem.  There needs to be in house experts to fix the problem and not outside consultants who typically know a lot less about problems and solutions.

Q:  What do you think is important about the 100 Miles 100 Stories Walk?

It raises public awareness about this issue and how it impacts health care workers. It might raise awareness about the expectation that it is part of the job and that many people expect health acre workers to accept it.  Hopefully it will also increase solidarity on this issue.

I should have added my opinion that there needs to be a zero tolerance rule for violence and aggression to healthcare workers.  They are after all doing their job taking care of people.

Q:  Is there anything else that you would like to cover?

I would like to mention that there are basically three groups the become violent in health care settings.  The first is people with severe mental illnesses who are making decisions based on a delusional thought process.  The second are people with acute or chronic intoxication states who are agitated or aggressive based on their use of an intoxicant.  The third group are people with personality disorders where aggression is a strategy or way of life.  Limits needs to be established with this group and they must be held accountable.

The interview ended at that point but there was obviously a lot more that could be said.  Like most people - I write a lot better than I speak.  I am sure that if you see the eventual clips I will be much less articulate and probably confabulated much of what I just wrote.

There is also a time constraint for these interviews and the consideration that the public probably wants to hear about the  general rather than the specific problems or proposed solutions. Certainly nobody has been flocking to this blog over the past years for my suggestions about violence or homicide prevention. 

I doubt that many people are aware of the fact that it is common that patients need to be physically restrained so that they don't injure themselves or anyone else.  I can recall being in an ICU setting when a young man suddenly got out of bed and started swinging an IV pole around his head.  An IV pole has a heavy metal base and anyone struck by that base would have been seriously injured.  He was doing this within a few feet of critically ill patients and the ICU nursing staff.  He was also delirious and completely unable to respond to verbal requests or guidance.  That is an illustration of how rapidly one of these situations can develop and also why there is a necessity for being able to respond to the problem rapidly.

I also might have discussed the informal triage system for dealing with violence or aggression.  In Minnesota not all hospitals will receive patients with this kind of problem.  Not all hospitals train their staff to physically intervene in an appropriate way.  In most health care facilities the training ends at how to approach the potentially aggressive patient and it assumes that the verbal intervention will be successful.  That will not work with very aggressive patients and training needs to include more specific physical measures.

There is also a lot of room to discuss environmental safety plans.  What is the physical design of the clinic or hospital ward?  Can changes in the design configuration provide additional safety for patients and staff.  In some cases it is just putting receptionists in safe areas where they are not in danger from walk ins or aggressive patients.  Does there need to be a law enforcement presence?  What about internal security?  What kind of plan needs to be in place to coordinate all of the personnel in emergencies?

Whatever the focus - these discussions need to get out there for the general public to consider.  The level of injuries to hospital staff and in some cases patients needs to improve greatly.  I emphasize again that the majority of these injuries affect nurses and nursing assistants.  Physicians have been  homicide victims as the result of some of this aggression.

In the cases of conscious directed violence - the perpetrators of that violence need to be prosecuted.  No health care employee should go to work every day fearing assault and in some cases disabling and career ending injuries.   

George Dawson, MD, DFAPA

Supplementary 1:

I was sent this link to an incident of emergency department violence from 1993.  That highlights the chronicity of the problem and the lack of effective solutions.  Quotes from the article:

"Health care workers noted, however, that the incident is only the most recent example of the rising tide of violence that has spilled over into the nation's urban emergency rooms."

"County-USC has been no exception. During the first six months of 1991, for example, security guards at the hospital responded to 1,400 reports of threats or attacks, six of which led to arrests. Among the assailants was a panhandler who approached four nurses in the cafeteria and plunged a pair of suture-removal scissors deep into one nurse's neck."

Supplementary 2:

Here is a link to the video I recorded that was the basis for this post.  It is a 4 minute clip edited down from about 20 minutes of interview material.  I had no role in the recording or editing of the clip.

George Dawson, MD on violence toward healthcare workers in psychiatric settings. Clip

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