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Dealing with agitated patients: Balancing staff safety and duty of care to the patient

18 Sep 2013, by Informa Insights

Jonathan Knott
Jonathan Knott

Being submitted to a hospital can be a stressful and unprecedented experience for a patient. At the same time, hospital staff has to deal with a number of different demands and constraints. In the lead-up to the Safe and Secure Hospital Conference, we had the chance to speak to Associate Prof Jonathan Knott, Head of Emergency Research at Royal Melbourne Hospital (RMH) and Clinical Sub-Dean for Emergency Medicine, University of Melbourne about the intricacies of safety and security in the hospital setting and best practice in risk assessment.

IIR Healthcare:  What are the greatest safety and security risks in hospitals?

Jonathan Knott: For patients, and the staff caring for them, the ideal environment is one where staff has access to all relevant information to work with a patient to get the best outcome. The risk of an adverse outcome increases when the environment forces shortcuts to care or when there are barriers to getting the requisite information. Such barriers can exist when the patient is critically ill, or uncooperative due to mental illness or intoxication. This increases the risk that a patient is managed a in a different way than it would be the case if all facts were known. Unfortunately, there has been a general increase in levels of intoxication and street level violence coupled with a reluctance of other institutions to manage these complex cases. The Emergency Departments become the default destination for these patients, especially after-hours.

IIR Healthcare: What are the best strategies for mitigating and preventing violence?

Jonathan Knott: For organisations this is multi-pronged. Good governance includes establishing policies that clearly state what is acceptable behaviour and how to manage issues such as weapons or anti-social behaviour. Organisations should have multi-disciplinary committees that are able to review serious incidents and also monitor trends to improve the response to violence in general. All staff should be trained in how to respond to aggressions and violence. Those working in high risk areas such as ED and Mental Health will need more training than other areas but the sad fact is that there are few areas within hospitals immune from such threats. Providing staff with the opportunity to get training is a much larger barrier than the specifics of the training itself.

IIR Healthcare: In your experience, what are the most effective risk assessment and control strategies for managing aggressive behaviour?

Jonathan Knott: Safe and secure hospitals conferenceFor our Emergency Department at Royal Melbourne Hospital several strategies have been introduced with a noticeable impact. We established a dedicated assessment area for highly agitated patients. The area allows de-escalation and containment in a far less restrictive manner than an open plan ED. This has been coupled with a long-standing additional nursing resource on all shifts dedicated to these patients. Having a dedicated nurse to assess for increasing agitation and respond early dramatically decreased the need for more restrictive practices such as sedation and restraint. Overall, RMH has made a significant commitment to getting staff in high risk areas the training they require. An active group of clinicians works on this training, governance and future strategies; essentially this is seen as a critical issue and attended to accordingly. Finally, but importantly, there are very good relationships established through long collaboration between areas that face common issues related to clinical aggression. The sharing of ideas and common approaches where practicable improves patient outcomes.

IIR Healthcare: How can hospitals improve staff safety and minimise workplace aggression? Are there any other industries we can learn from?

Jonathan Knott: If we are considering clinical aggression then I think we need to be careful about looking outside to other industries. Ordinary bad or criminal behaviour is a police and security issue but clinical aggression is complicated by the conflicting responsibilities to staff safety and duty of care to the patient. To some extent, this conflict always exists but well-trained staff working in a supported environment can manage the vast majority of issues extremely well. However, the complexity of some cases should not be underestimated. There are particular patient groups that are especially challenging. These include patients with intellectual disability, paediatric and adolescent patients and obstetrics (where the issue is almost always with the partner of the woman).

IIR Healthcare: You will be speaking at the Safe & Secure Hospitals 2013 conference, to be held on the 24th and 25th October in Sydney. What issues do you think the healthcare industry needs to address to achieve a safer and more secure hospital environment?

Jonathan Knott: As an industry we need to ensure that our approach to aggression and violence within our hospitals is managed as well as it can be from both the perspective of our staff and of our patients. We need to have the right structures in place, create the best environments for care and get out staff trained adequately. There is no solution that will apply equally to a large tertiary city hospital and a small remote hospital but there are common threads that can be incorporated into structures, policies and training programs. Importantly, there is a great willingness to share current ideas and experience. This allows the successes and failures across a breadth of organisations to be the basis of continuing improvement by all of us.

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