Luncheon Consensus - Management Continues To Do Nothing About Hospital Violence

I had lunch last weekend with staff from several psychiatric facilities in the Twin Cities.  The group included nurses, nurse practitioners, and health unit coordinators.  Many of them were at the retirement party that I described a couple of years ago.  At one point in time we all worked on the same inpatient unit and that was the common bond.  Over the several hour long lunch the discussion gravitated to one of our favorite topics - violence and aggression in hospitals against medical and nursing staff.  There was the usual litany of injuries - concussions, a stabbing, beatings, and musculoskeletal injuries.  At one point I heard how a staff nurse in her fifties with knee replacement surgery and back problems had to interject herself between a patient she was admitting and a violent and aggressive person who walked in off the street.  In that situation she had to hope that security got there in time to protect her.  I listened to another nurse tell me how the assault charges were determined after she was assaulted - first degree assault only because she had a concussion.  The other forms of being punched and kicked that she sustained that day were all lesser forms of assault.  I also heard how some members of the hospital administration minimized the incident and how her assailant eventually was not charged with anything.

This is one of many areas where the army of health care administrators really don't seem to be able to do anything productive.  Every hospital in the country has posted non-discrimination policies.  They discuss how every patient will be treated respectfully.  These same rules do not apply to their own staff.  When staff are assaulted there is a common belief that it is an occupational hazard.  It is all part of the job.  The other crucial part of the problem occurs at the committee level in higher levels of administration.  When ever there is a potential problem resulting in injury, a standard administrative strategy is to move it to a committee or Task Force.  That is where real problems occur because there is no expertise on the committee in assessing and resolving problems with violence in medical settings.  That lack of expertise is common.  A corollary is that administrators are in the position that they do not believe that they can defer to clinical staff with much more expertise because of the chain of command.  That is a recipe for inaction and manipulation.  If a staff person brings up a concern that the administrators can't solve - the issue is tabled or the person is not asked to come back.  Even more problematic, some administrators embark on their own ideas about how to solve the problem.  I have listed some instances of this happening on this blog that have resulted in more staff injuries.  A final strategy is to bring in consultants.  I have seen situations where expensive business consultants are brought in to either tell the staff that their patients are not any more aggressive than the patients seen in other hospitals in the state.  If that doesn't work - bring in a consultant who will try to demonstrate that he or she knows more than the current staff.  Both administrative strategies fall flat when the staff is dealing with some of the more significant problems with aggression in the state and they have the most experienced clinicians.

No - the violent outbreaks that are described in most hospitals are the result of administrative failures at several levels.  A failure to recognize the issue exists.  A failure to recognize that your staff has the expertise to deal with it.  A failure to recognize that aggression toward the staff is not the result of staff failing to treat people in a particular way or due to a deficiency of the staff person.  And most of all - a failure to facilitate a team approach among the staff in the hospital or clinic with the most expertise.  It is really that easy.

In our discussion, several instances of these manipulative responses to hospital violence were noted.  Even very basic requests for additional security staff and to prevent aggressive people from walking in off the street are ignored.  There is no shortage of meetings and I have participated in many.  One of the administrative strategies is blaming physicians for the problem.  There is nothing like having a dedicated and skilled staff with as much expertise as can be found anywhere - suddenly being blamed for the problem.  In some of these situations the administrators bring in "consultants" to tell senior clinics who have been treating the problem for 20 years.  I am speculating that is right out of "Power Plays 101" in administrator school.  It is not difficult to see how all of this administrative drama and expense fails to solve the problem.  In most cases it ends up looking like nobody is even trying.  A scapegoat has been found - let's leave it at that.

There has been a laudable effort by nurses.  In my home state, the Minnesota Nurses Association (MNA) has been very vocal in terms of the number of aggressive incidents toward nurses in Minnesota hospitals very year.  A 2004 study showed that that nurses were physically assaulted at a rate of 13.2 assaults per 100 persons per year.  17% of nurses were threatened and 34% were verbally abused in the preceding 12 months of the study.  The MNA has also been active to get legislation to legally protect nurses from aggression and assault.  This link to their proposal does not indicate whether either of their proposals have been successful.  

It appears that there are no comparable efforts by the state psychiatric association or medical association.  I am sure that if this luncheon group meets again, there will be reports of further injuries and a continued lack of response to the violence and aggression toward health care workers.

It probably makes sense in terms of the American inertia in dealing with violence and aggression in general.  But it also makes sense because health care administrators really don't do anything to support clinicians or improve the environment where they work.

Replacing all of those administrators is the best place to start.



George Dawson, MD, DFAPA              


References:

1:  Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. Review. PubMed PMID: 27119238.

2: Nachreiner NM, Gerberich SG, McGovern PM, Church TR, Hansen HE, Geisser MS,Ryan AD. Relation between policies and work related assault: Minnesota Nurses' Study. Occup Environ Med. 2005 Oct;62(10):675-81. PubMed PMID: 16169912; PubMed Central PMCID: PMC1740877.

3: Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, Ryan AD, Mongin SJ, Watt GD. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occup Environ Med. 2004 Jun;61(6):495-503. PubMed PMID: 15150388; PubMed Central PMCID: PMC1763639



Supplemental:

Aggression and violence and their prevention is one of my interests on this blog.  A sampling of posts can be found at this link or by selecting any of the links from the right margin.

A Real Case Of Psychosis And What Can Happen

Public radio continues to be a rich source of information when it comes to real life psychiatric problems.  In this case the NY Times was also involved.  Considering the date the story was filed the usual critics have not chimed in yet.  They may not be able to since no psychiatrist or psychiatric medication was involved in the care of this patient - and it shows.  There is no more compelling story that psychiatric disorders exist, are severe, and for various reasons can end catastrophically.  I won't  belabor the point that I have treated hundreds of people with very similar problems.  For 22 years, I treated people with severe psychiatric disorders and most of them had psychotic disorders.  The episode of psychosis described in this story is the kind of psychosis that psychiatrists treat, not the vague symptoms described in a recent paper that suggested that some symptoms of psychosis are a normal experience.

Before I get into a brief discussion of the scenario, I would like to acknowledge the patient Alan Pean for sharing his story.  I heard his story on This American Life and the host Ira Glass was explicit that Mr. Pean  had signed a release of information so that the hospital records and a 50 page report of the incident could be used to construct what had happened. His family members were also available for the interview.  In this age where health care companies view patient information as proprietary corporate information I applaud Mr. Pean's decision to make this very personal private information public.   There are numerous lessons to be learned from this incident that I hope to make explicit  at the end of this post.

For anyone interested in listening to the audio version of this story go to the This American Life web site and look up episode 579 My Damn Mind.  This amazing story begins after Mr. Pean has been shot in the chest and is bleeding to death on the floor of his hospital room.  There is blood  everywhere on the floor and people entering the room have to put on shoe covers.  Later in the story we learn that he lost about 1/3 of his total blood volume.  A trauma surgeon is demanding that the police take the handcuffs of Mr. Pean because even though he is shot and immobile, he is handcuffed lying on the floor.  According to the Centers For Medicaid and Medicare (CMS) report he was trying to get up after he was shot and saying that he was "Superman". From there,  Ira Glass starts to interview Mr.  Pean about the 20 hours prior to this incident.  He describes being anxious and at times panicky.  He was sleeping 4 hours per night and recognized he was manic from his past experiences in 2008 and 2009.  He was diagnosed with possible bipolar disorder treated with medication and had no further episodes in 6 years.  He was trying to unwind by playing a video game online with his friends.  He started to think that the video game controller had been reprogrammed by the enemy and was switching on a processor inside of him.  He could not logon to the game because he knew that drones would triangulate on him if he did and destroy his apartment.  He called his brother for advice.  His brother told him to lay down and put cold water on his face.  He concluded that his circuits were overheating like a robot and his brother knew this.  At one point he knew he had to escape from his third floor apartment balcony because snipers were closing in on him.   As he looked down he thought remember your training - you are trained for this.  At that point Ira Glass jokes with him about that point and they both laugh.  He of course had no training and it was apparent to me that Glass had not talked with many delusional people.  Pean executes a perfect drop to the second floor balcony and grabs the railing.  From there he notices two air conditioning units on the ground swings past then and jumps.  He hits the ground running for his car because he has called in a drone strike in his apartment building using Google Maps.  He jumps in his car and heads out of the parking lot.  When the gate doesn't open he rams it until it opens.  At this point he is thinking that his rendezvous point is the hospital.  In a moment of clarity he also realizes that he needs Geodon, the medication that he takes for psychosis.  He feels like he is a bionic person or a cyborg driving the car at a high rate of speed toward the hospital.  As he approaches, he loses control and hits several autos and the hospital building totaling out his car.  An EMT sees the crash. puts him on a gurney and wheels him into the Emergency Department.

This entire sequence of events was driven by delusions.  In the narrative Pean described an intense fear for his life and the fact that his "adrenaline was pumping" at times.  That combination of emotion, especially high anxiety and delusional thinking can lead to impulsive behavior and a lack of typically rational decision-making.  It is an example of "dangerousness" or the emergency criteria that governs whether a patient with psychiatric problems is offered inpatient treatment or not.  The problem is that Pean's actions are all internally consistent with his delusional state.  He talks with his brother on the phone and does not mention that he thinks he is delusional.  In this state of mind, it is very likely that anyone assessing him for "dangerousness" would seriously underestimate what he was capable of.  A lot of his acts are also environmentally determined.  His delusional biases interpret the information as he sees it.  When he was speeding toward the hospital, he was convinced that some of the buildings he was passing were going to explode at any minute.  Despite the non-psychiatric interview, I think the emotion driving the delusionally based decisions is apparent.  Ira Glass points out that the narrative though irrational is internally consistent like a movie and not what he expected.

Pean is eventually admitted to the trauma surgery service for further observation of injuries from the car crash.  There was ample information that he had a significant psychiatric disorder including direct statements from his father who is a physician.  He is noted to be disoriented and believes that it is 1989.  His speech at time is incoherent, but the staff observe him to be lucid at times.  Immediately prior to the incident, several staff report the patient coming out of his room into the hallway either nude or partially clothed.  He had to be redirected back into his room and asked to put a gown back on.  He was dancing and in some cases danced away from staff trying to help him into the gown.  With his history (and assuming that brain trauma has been ruled out) these can all be features of a severe psychosis.  His parents are concerned that they plan to discharge him without psychiatric consultation.  The hospital they are in does not have an acute inpatient psychiatric unit and he has not seen a psychiatric consultant.  They leave at some point to rent a car so that they can drive him to psychiatric facility if necessary.  While they are gone he becomes extremely agitated.  He is tasered several times and ultimately shot in the chest just 40 minutes later.

The New York Times article goes into detail about the issue of armed security in hospitals.  It reviews the number of people with mental illness who were shot or tasered and killed.  I have pointed out some of the problems with firearms in psychiatric hospitals in an article about visitors carrying firearms into Texas state psychiatric hospitals.  The same issues apply in this case.  Firearms are not a deterrent when confronting a person who is agitated and psychotic.  In this case the patient recalls that he was some kind of cyborg secret agent.  In that frame of mind he is likely to interpret any efforts to contain his agitation and aggression as potentially dangerous to him and it would provoke extreme behaviors to counter that aggression.  In every security setting where I have worked, security and law enforcement lock up their weapons and do not take them into patient care areas even if a patient is highly aggressive and out of control.  It takes well trained staff and security to be able to do this and recognize why this is the best approach.  It also involves a contingency plan to physically restrain the patient in a safe manner as quickly as possible if the patient does not respond to verbal deescalation.

The CMS document discloses several important pieces of information that are not in the media.  The first eye opener is that the hospital administration said the security officer was justified in shooting the patient because he had assaulted them.  That statement grates on any inpatient psychiatrist or nurse who recognizes that is not the appropriate frame of reference for this incident.  This is not a street fight.  This is a vulnerable patient in a hospital whose rights and standard of care needs to be recognized.  One of the implicit assumptions in most hospitals is that psychiatrists and psychiatric staff are supposed to view aggression as an occupational hazard.  A unidentified staff member speaks to that in the radio piece and is very explicit about the amount of aggressive behavior that he sees in the hospital and the fact that he gets hit.  That is not the case in other parts of the hospital where aggressive behavior is more frequently seen as criminal behavior.  Early statements from the hospital administration suggested that the law enforcement officers here were justified in shooting Alan Pean, but they were subsequently modifying their position.  He was also charged with 2 counts of aggravated assault on both of the law enforcement officers who entered his room.  Clearly this is a psychiatric problem and the patient needs  protection.  As I read through the 50 page document from CMS, the suggested solution varied from being vague to solutions that many hospitals already have such and an emergency response team for behavioral emergencies.  They suggest that armed law enforcement officers should be only in the ED, not be involved in the behavioral emergencies until all other resources have been exhausted and intervene only in the case of life-threatening or criminal activity.

One of the primary conclusions of the This American Life piece is that is could have been prevented if the patient had received a psychiatric evaluation.  A hospital staff person pointed out that this was standard procedure and also that any number of staff used to encountering aggressive patients could have contained the patient without firearms.  There is apparently an inpatient psychiatric unit at this medical center where he could have been transferred.  Alan Pean responds to Ira Glass's question about how it is that he went to the hospital with mania and psychosis and ended up getting shot in the hospital instead.  One of his conclusions is that he is a young black man and he does not think that it would happen if he was white.  He remains understandably traumatized by his near death experience.

The only logical conclusion here is one that I have already reached many times in many posts on this blog.  Violence and aggression are treatable problems when they are associated with psychiatric illnesses.  There needs to be psychiatric and psychiatric nursing expertise in major hospitals at several levels.  One of the unusual parts of this story was all of the information available suggesting that the patient in this case had a significant mental illness.  That was made even clearer when his physician father made the statement, requested the psychiatric evaluation, and was told that the patient was being discharged instead.  The CMS report does not address staffing levels in the hospital and whether there are adequate staff to address the problem.  In my experience, a nurse and another staff person going to address a situation where there is potential aggression by a young manic patient is not enough staff.  I have personally found myself in many situations when I walked in a room and there were four highly trained nursing assistants out in the hallway, ready to intervene if necessary.  In every case our goal was to protect the patient from injury.

The lesson in this case is that if you go to a hospital with aggressive behavior due to a psychiatric disorder somebody on the receiving end needs to know what to do to keep you safe.  Only a fraction of American hospitals are set up to do this and provide the necessary psychiatric care to resolve the crisis.  Some hospitals will never be equipped to deal with this problem and the practical solution in most communities is to triage violent and aggressive people to more appropriate facilities.  Even though the New York Times article points out that there has been a 40% increase in hospital violence, many of the people with that problem never make it there.  There needs to be enough capacity to treat people so that people with violent and aggressive behavior from a psychiatric illness can go to a hospital knowing that their problem will be diagnosed and treated and that their safety will be assured.  
             
Nobody should ever have to experience what Alan Pean went through.



George Dawson, MD, DLFAPA




References:

1:  This American Life.  579: My Damn Mind.  February 12, 2016.

2:  Elisabeth Rosenthal.  When The Hospital Fired The bullet.  New York Times February 12, 2016.

3:  Department of Health and Human Services Centers for Medicare and Medicaid Services.  Statement of Deficiencies and Plan of Correction.  St. Joseph Medical Center; 1401 St. Joseph Parkway, Houston Texas 77002.


Supplementary 1:

In the report by This American Life, it was apparent that at least some authorities were looking for evidence that the patient had aggressive tendencies outside of the episodes of mania and psychosis.  They did this by asking his family if he had any criminal convictions.  In the original hospitalization he was also noted to have THC in his toxicology.  The fact that there were no other drugs present and that THC can persist a long time was emphasized in the This American Life piece.  In fact, THC is not a trivial compound in this case.  No conclusions can be made based on the existing data and the lack of direct assessment of this patient, but this compound should be avoided by anyone diagnosed with bipolar disorder, especially if there is any doubt about the diagnosis.


Twitter Graphic:

The CMS Investigation Of Anoka Metro Regional Treatment Center

In a previous post I discussed a recent local news article that pointed out the increase in incidents of aggression at one of the state's major psychiatric facilities and a threatened loss of Medicare funding unless certain deficiencies were corrected.  The deficiencies were determined by an investigation of the facility by the Centers for Medicare & Medicaid Services (CMS).  No specifies from the report were available from the news article or the Minnesota Department of Human Services.  They did provide me with a contact person at CMS and after another forwarded e-mail, I was sent 4 attachments detailing the results of the investigation.   I will report on those reports in this post.  The documents were all typed on a standard government form as noted in the graphic below.  The entire CMS report is written in the column labelled "Summary Statement of deficiencies...".  No comments were written in the column labelled "Provider's Plan of Correction...":

I have coded them AMRTC 1-4 for convenience and will refer to them that way in the summaries below.

AMRTC-1 is a 34 page document that states the visits was done to see if the hospital was in compliance with 42 CFR Part 482 for acute care hospitals.  The survey was conducted from 10/19 to 10/23/2015.  The report indicates that there is a 108 patient capacity at the facility and that 30 records were reviewed as the basis for the report.  Problems were found in 2/30 cases with regard to patient care.  There were additional administrative problems that also resulted in noncompliance with the federal standard.  There were problems noted  It was determined that the hospital was not in compliance with the Conditions of Participation of 42 CFR Part 482.  The main finding of the first report is that The Governing Body of the hospital failed to ensure that services provided by staff or contracted staff were proved in a safe and effective manner.  The highlighted areas include failure to assure that quality processes were in pace to minimize or prevent medical errors, failure to assure that comprehensive nursing plans were developed, and a patient's rights condition that occurred when a patient was given forced medications that were prohibited by a court order.

The Quality Assessment Performance Improvement (QAPI) programs extended across a number of clinical and nonclinical disciplines.  In some cases,  they involved the administration not doing what they stated they would do in their descriptions of quality improvement.  The best example I can think of is the reference to Six Sigma.  I have always found it a questionable practice to apply engineering management processes to any medical field.  I sat through a presentation of this paradigm in a previous job and it just seemed like the standard management buzzwords that we hear in different iterations by people who think they are inventing management every 5-10 years of so.  At that job we suffered through a couple of presentations and printed Powerpoints and it faded as soon as it came up.  We moved on to a different paradigm.  Since it was widely promoted, the Six Sigma approach has been shown to not be uniformly effective in business and manufacturing models.  What the proponents of Six Sigma to medical fields don't seem to understand is that measurement is a limiting factor and it has nowhere near the precision or accuracy of measuring products in electronics or automobiles.  At the philosophical level the administration probably made the common error of espousing a philosophy that they could not live up to.  I am not aware of any major healthcare corporation that uses the Six Sigma management model and they probably have many more resources than a state hospital. 

One of the case examples cited was an agitated patient who was physically aggressive and received olanzapine and then intramuscular haloperidol despite a court order excluding haloperidol and risperidone.  The psychiatrist and nurse involved were questioned and said they were unaware of the order at the time the medication was administered.  The patient got this medication for a period of 3 days before it was discontinued.  CMS investigators comment how the physician in this case could be held in contempt of court for ignoring a District Court judge's order.  There was a question of whether or not there were two different orders and the one barring the medications showed up later.  As a physician who has worked with different court orders in these cases for over 20 years, I can attest to the fact that they are not necessarily clear.  In many cases there is a temporary order until the final document can be typed up.  It would seem that the quality process here would be to appoint a person to make sure the latest order is in the chart and read by the attending physician before any medication orders are written.  There is also a question of how paper documents from the court are placed in an electronic record and how easily they can be read in that record.

At the end of the document problems with the care of 10 different patients with different diagnoses and problems are reviewed.   These clinical examples were given to illustrate that that patient with varied problems were all given treatment plans that were not comprehensive, even in the case of patients with aggressive or self injurious behavior.  The reports describes this as: 

"Interventions on the Patient Treatment Plan were generic and were normal functions of the professional disciplines involved in the patient's care and were not individualized to the patient."  

What does all of this mean?  A recent article in the StarTribune (1) had quotes from several mental health experts and advocates about the state of affairs at AMRTC.  The commentary seemed to vary in the level of outrage expressed as "egregious" and "appalling" and "no excuse."  As an expert - when I read the report it seems to scratch the surface.  Would correcting the deficiencies in the report right the ship out at AMRTC?  Possibly - but the previous news report suggests there is a much bigger problem.  That report was about incidents  of aggression, how they were increasing, and there was an opinion that aggressive inmates transferred based on new legislation was the main reason.  A union representative was quoted as saying that some of the inmates transferred from correctional facilities had "taken over" and that they were more aggressive than non-correctional patients.  None of those problems are specifically addressed in the report.  The report comments on problems in the care of specific individuals, only one of whom seem to be as aggressive as two of the patients mentioned in the original article (2).  The errors in the report may be largely documentation and reading errors, but administrators always emphasize "if it isn't documented it did not happen."  Some of the problems at AMRTC have been decades in the making.

For a long time the message given to most professionals in the state is that the state hospital system including AMRTC (like practically all other hospitals in the state system) was going to be shut down. Only the practical fact that there is always a backlog of committed patients waiting to get in to AMRTC prevents it from being shut down.  But the key question remains - is this really the attitude of managers at the level of the State of Minnesota?

The second problematic attitude that I have heard about constantly is written about in the recent article (1):

"Nearly half of the 101 patients currently there no longer meet the hospital-level criteria for care but are kept at the hospital because they have nowhere to go in the community. In 2013 alone, patients spent a total of 13,800 unnecessary days at Anoka-Metro after they were treated — enough to care for another 140 patients, according to a state legislative report."

This is a good example of circular reasoning.  The reason why patients spend so-called "unnecessary days" at AMRTC is that there are no other facilities that can manage their behavior.  I am aware of programs where very aggressive individuals are managed in very small settings (2 to 4 resident group homes) and the staff is taught to physically restrain them when they become very aggressive.  That is really an unacceptable long term solution to the problem for many reasons.  It is time to stop pretending that long term hospitals are acute care hospitals and that they should be managed like acute care community hospitals.  A transient reduction in symptoms does not mean that a patient at AMRTC is spending "unnecessary days" at the hospital.  If they cannot successfully transition to a community placement - they probably need to be there.

The real and unaddressed issues (beyond the CMS report):

1. The effect of the message that state hospitals should all be closed: As a psychiatrist in the state, this is what I have been hearing for a long time. It is really not possible to develop a quality of care focus or have the necessary stable staffing patterns of experienced staff, when those same staff are hearing that the state is trying to close down the facility and that many people at the facility don't need to be there. Instead - the facility should be managed as one that can provide state-of-the-art care to patients with complex problems including violence and aggression. Another aspect of that is eliminating the positions of experienced staff to save money. You will never have a high quality program using this approach and yet the state has used this approach.

2. The effect of management from higher levels: This seemed to stand out as I read the issue of "generic treatment plans" from the CMS report. At some level all treatment plans become "generic treatment plan". The evidence is that you can purchase treatment planning texts for nursing, psychotherapy and to a lesser degree psychiatry that will show you generic treatment plans for an entire list of problems. Is the problem really a generic treatment plan that covers most interaction or the lack of a treatment plan that addresses a high degree of aggression? I would contend that it is the latter.

Complicating that issue are previous stories about how plans were implemented by state administrators with no psychiatric experience to address patient aggression. I sat in on one of these sessions that suggested that a focus on the aggressive person as a psychologically traumatized individual was the best way to proceed, but not much specifics after that. Is at least part of the problem that state hospital staff have inadequate guidance on what to do about aggression? Are they reluctant to intervene early or clearly document what happened and their response because the response from administrators is inconsistent? Are they being advised to use interventions that are ineffective?

3. The lack of teamwork and possibly a split staff: One of the most dangerous problems in any inpatient psychiatric environment is staff splitting - some of the staff are praised and well liked and other are criticized and disliked. This emotional environment in inpatient care leads to problems in patient care. Splitting needs to be minimized or eliminated largely by recognizing that professionalism and the objective analysis and treatment of problems is the real priority. I have been in treatment environments where staff were disliked or falsely accused and that lead to major problems in patient care and episodes of aggression. It also leads to staff turnover.  The attitude of administrators can be particularly insidious and create an immediate rift among the staff.

4. The influx of inmates into AMRTC that is caused by the current public policy of rationing community psychiatric care and the resulting shift in the cost of care to the correctional system: Instead of addressing the widespread problem of rationing psychiatric care for the severely mentally ill - the solution is currently to dump at least some of them from law enforcement facilities to a rationed long term care facility. How is that a solution to anything?

These are the real problems at AMRTC and within the state system as far as I can tell. This is all based on what I read in the papers, the CMS report, and my extensive inpatient and out patient experience as well as experience treating aggressive people. The CMS report while noting significant problems does not come close to addressing these issues and makes it seem that addressing problems in patient care or documentation will correct the problem with aggression within this system.

I doubt it is that easy.



George Dawson, MD, DFAPA


1:  Chris Serres.  Anoka state mental hospital violated basic rules for patient care, feds say generic treatment plans, other issues put mental hospital's federal funding at risk. StarTribune January 16, 2016.

2: Chris Serres. State psychiatric hospital in Anoka threatened with loss of federal funding. Minneapolis StarTribune January 4, 2016.

More On Violence And Aggression In Minnesota Hospitals

There was a recent incident (see link within that article) that occurred in a Minnesota hospital a few weeks ago that resulted in serious injuries to nursing staff.  There are various sites on the Internet where you can view the videotapes that were obtained from the hospital's security cameras.   It shows an out of control man chasing and striking nursing staff with a metal bar or pipe, in some cases repeatedly.  The patient in this case was eventually apprehended outside of the hospital and died suddenly after he was tasered, taken to the ground, and handcuffed.   Preliminary information suggested that the patient involved in this situation was probably experiencing an acute change in his conscious state because it was a total departure from his personality and he had no previous episodes of aggression or violence.  Nursing staff sustained serious injuries including a pneumothorax.  Autopsy results have not been released at this time.

Many people were shocked by this activity and yet is is a fairly common occurrence.  People may expect this kind of agitated and aggressive behavior to occur only on psychiatric units, but the reality there is that is happens only on a few psychiatric units.  Most psychiatric units are managed to limit the admission of patients with a high potential for violence.  It happens on medical-surgical units for a number of reasons and the effects are more dangerous at times because of the availability of objects that can be used as weapons.  I have seen stands used for hanging intravenous solutions being swung in a wide circle through an intensive care unit.  These stands have heavy bases that can inflict serious injuries and destroy a lot of equipment in an ICU.  There are many possible reasons for this kind of aggressive behavior ranging from delirium and psychosis on one end of the spectrum to antisocial behavior and wanting to intimidate medical staff on the other.  Although it seems incongruent with a controlled hospital environment, many families have an experience with a family member who suddenly loses control.  The proscription on aggression and violence and the moral interpretation of this behavior often makes it difficult for families to comprehend what is happening.  Families and medical professionals alike often lack the vocabulary for describing this behavior and can just lump it together as "bad" behavior.

I saw the preliminary description of this incident and the video clips and decided not to comment on it until after the results of the autopsy and investigation were known.  The idea that  this problem would be approached by making this behavior illegal made me change my mind for a couple of reasons.  First, there is a very high probability that this behavior was precipitated by a medical problem that led to a change in consciousness to the point that this individual had no control over his behavior.  Anyone who has been delirious has experienced this at one point or another.  In my own family one of the male relatives who was a well driller was apparently "blown up" in a well one day and the resulting brain injury led to permanent and extreme changes in his behavior.  From that day on he was extremely aggressive and the aggression was directed toward property.  He continuously overturned furniture and smashed dishes until the entire house was trashed.  In those days before any care or containment was available, the expectation was that the family would care for him and they did until he died.  The home environment was constantly disrupted by rage attacks until that day.  In my capacity as an inpatient psychiatrist, I would routinely see people brought to the hospital after they suddenly became aggressive at home.  When their relatives arrived they were always shocked to find that the patient had been admitted to a psychiatric unit.

My second reason for concern is the involvement of politicians in what is a misunderstood medical problem.   An acute medical problem causing aggressive behavior in not a criminal act - it is a medical problem.  Attempting to incarcerate or fine a person for aggression that occurs in that circumstance does not make any sense at all.  It may be a way to secure political capital from a special interest groups, but criminalizing a medical problem is not a reasonable approach.  Even suggesting that this is something that should be debated in a court of law is questionable.  I base that on the known track record of the not-guilty-by-reason-of-mental-illness defense.  It is widely known that there is a low probability of that defense succeeding.  It is also widely known that people who have committed criminal acts and who clearly have severe mental illness  are typically convicted.  All it usually takes is a expert testimony suggesting that despite any mental illness diagnosis, the defendant appeared to be taking planned steps to achieve a goal.  In the case of aggression those steps would involve assaultive behavior and destruction of property rather than random activity.  I can say that in every case of aggressive behavior that I have witnessed in a hospital, even in cases where the patient had no subsequent recall of the incident that their behavior appeared to be planned and the assaults were directed.

On the non-medical side of the spectrum, there are people whose conscious state is not altered at all and they have directed violence as part of their personality structure.  Threatening and assaulting people are a way of life.  They frequently have criminal backgrounds or an arrest record.  They often give a history of fighting and may have harmed someone when they were defenseless or felt no remorse if their aggressive behavior resulted in injury or disability.  In my experience the majority of these persons can control themselves in medical settings with a few exceptions.  Any drug or alcohol intoxication state makes them more unpredictable.  Seeking prescriptions for controlled substances like opiates or stimulants can also create confrontations if they don't get the prescription that they are seeking.  There may be a question about whether any special legislature penalizing what is essentially criminal assaultive behavior would be useful.  My guess is that it would not for the same reason that civil commitments fail to work - the laws are not utilized.  Hospital administrators and courts tend to ignore aggression toward medical and nursing staff from patients who are willfully directing violence toward them as a product of their usual conscious state.  Administrators always explained it to me as an occupational hazard, especially on the part of the nursing staff.  That casual attitude often leads to inadequate safeguards at every step.  There should be a zero tolerance attitude for personality disordered violence and that should include prosecutions for assault.

The key to protecting medical and surgical staff and their patients from aggression associated with acute changes in consciousness is to have a heightened level of awareness.   The patient's history prior to admission is critical.  Prompt recognition of delirium from many causes and acute drug and alcohol intoxication and withdrawal states is necessary.  Adequate staffing is critical.  There needs to be a definite team approach, all of the staff on the unit need to be aware of the potential for violence, and the priority needs to be on protecting the nursing staff delivering direct care to the patient.  Medical staff and nursing have to be on the same page and there can be no factors present that lead to split treatment.  Enlightened administrators may be helpful in preventing that dynamic, but in my experience I have not found any.

One of the common problems is that staffing on some of these cases involves 1:1 observation preferably by a trained psychiatric technician or nursing assistant who knows how to help patients de-escalate.   Just having a reassuring person in the room can often have the same effect.  There are protocols that address the physical environment to reduce the likelihood of post operative delirium.  Where necessary it is useful to have experienced staff treat acute agitation in hospital settings with medications.  Some large hospitals have psychiatric consultation 24/7 to address the problem and in some cases where the patient is medically stable transfer them to a more secure psychiatric environment for assessment and treatment.  Medical and nursing staff need to be in close contact 24/7 in order to make rapid adjustments in the treatment plan.

Making the aggressive behavior associated with explainable medical problems a crime is the wrong approach.

When I see legislators talking about what medical professionals do or do not know about containing violence and aggression my typical response is to cringe.  I put it on the long list of all of the other things that legislators think they needed to train physicians in - like how to prescribe opiates (in the year 2000) and then how not to prescribe too many opiates (in the year 2010).  There are plenty of people who come out of training who known how to assess and treat aggression.

They are called psychiatrists and psychiatric nurses.




George Dawson, MD, DFAPA