The single best way to handle a violent patient or curtail the potential for violence in the emergency department is by prevention. Careful planning of the work area, cooperation with security, and training of all emergency department personnel to recognize violent patients are critical.

The physical plan of an emergency department should be one of controlled access. Visitation policies should be reasonable yet enforced. Some hospitals use visitor identification badges to monitor visitors in the department. A busy emergency department, packed full of visitors, only increases anxiety and tension. It is also the perfect place for a weapons-carrying violent patient to take hostages. Although a history from family and friends can be important in the evaluation of any potentially violent patient, interviews should be conducted in a safe, calm environment.

Seclusion rooms for interviewing patients should be safe for both the patient and the interviewer. Solid walls with sturdy, heavy furniture that would be awkward to lift should be used. Lighting should be able to be dimmed or brightened, depending on the circumstance. No free-standing objects, such as ashtrays, pictures, or pencils, should be allowed, since they all could become potential weapons. Exits should be clear of obstruction and readily available to the interviewer. Panic buttons may be installed or signals developed to be used in the event of threatening behavior on the part of the patient. If violent aggression does develop, the room should be large enough for a team of security personnel to safely overcome the patient without undue harm.

Deterrence is also a preventive technique. Signs outside the emergency department should clearly state that weapons of any type are not permitted, and trained hospital security personnel should be visible to everyone entering the emergency department. Not only does this set a tone of behavior, but security measures can be invaluable in preventing as well as curtailing any violence. The use of metal detectors and x-ray machines for personal articles, such as handbags, may allow for easy screening of those entering the treatment area. Once believed a luxury, metal detectors are now reasonably priced. Carefully placed monitors and alarm buttons may also be warranted. However, metal detectors, monitors, and alarms are only a part of an overall security system and complement personnel training in the management of potential and actual violent situations. —I!

Seclusion rooms and deterrent measures are needed, yet the education of the emergency department personnel is the most important factor in curbing violence in the emergency department. Several national programs, such as that offered by the National Crisis Prevention Institute, are invaluable in teaching a basic understanding of violent behavior, its recognition and management, and basic self-defense against violent patients. In-services by security personnel and law enforcement officials may also be of benefit. Physicians should learn how to examine a patient while still protecting their personal space in order to prevent injury should the patient lash out.

Common sense and a heightened awareness of the potential for violence is the first step in this education. Being aware of the position of one's body, clothing, and equipment in relation to the patient can save one from assault. The physician should never let a violent patient get between him or her and the exit. Physicians should defer to trained security personnel if a patient needs to be searched or disarmed. Incidents and reasons for restraint must always be properly documented.

Violence in emergency departments is not uncommon. Both rural and urban hospitals are plagued by increasing episodes of violence. Careful preparation and a heightened awareness of the potential for violence are basic. Education is important in understanding the dynamics of violent behavior and will help to detect and manage the violent patient. Training should be reviewed periodically. Management strategies should involve a team of emergency department staff and security, law enforcement, and hospital legal departments. Strict policies should be established for visitation. Making the work environment safe will make all involved more comfortable. Health care providers should feel as safe at work as they do at home. Physicians should trust their intuition. If the physician is afraid, then the potential for violence probably exists.

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