Violent Patients A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 Kendall L. Stewart, MD, MBA, DLFAPA December 20, 2013 1 My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms. 3 No one can reliably predict future violence, but imminent violence is easier to anticipate.
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Violent Patients A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 Kendall L. Stewart, MD, MBA, DLFAPA December 20, 2013 1 My aim.
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Violent PatientsA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2,3
Kendall L. Stewart, MD, MBA, DLFAPADecember 20, 2013
1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.3No one can reliably predict future violence, but imminent violence is easier to anticipate.
Why is this important?
• After mastering the information in this presentation you will be able to– Identify three factors involved in
patient violence– Name three disorders frequently
associated with patient violence– Specify three of the risk factors for
patient violence, and– Describe three practical steps in an
evidence-based process for managing potentially violent patients.
• Following this process may save your life.1
1 Some of you may have heard me talk about Jeff Hill saving my life.
What causes violence?
• A combination of factors is usually involved.– Internal agitation– Misperception– Feeling angry or threatened– Resentment– Blame1
– Disinhibition– Learned behavior2
• Underlying psychiatric conditions are common.• Substance abuse is often a factor.• Schizophrenia is the mental disorder most often
involved.3
• Many physical disorders are associated with violence.
1 A man threatened to shoot me because I mentioned ECT as one treatment option for his depressed daughter.2I often use the aircraft landing metaphor with adults who still throw temper tantrums.3Violence is associated with delusions, but the violence is worse when anger is a factor.
What are some of the risk factors for violence in the healthcare workplace?
• Increasing presence of gang members and drug users
• Low staffing levels• Isolated work with patients• Lack of staff training and
experience• Lack of readily available backup• Distraught family members• Poorly lit areas• Thankfully, the incidence of
workplace violence has declined since 1993.2
• The frequent presence of handguns and other weapons
• The frequent release of jailed persons to avoid payment for medical treatment1
• The presence of many acute and chronically mentally ill patients in the community
• The availability of drugs and money at hospitals and medical offices
• Unrestricted access to medical facilities
• Long waits with accompanying frustration
1 Local jailers frequently release prisoners outside our ED so they won’t be responsible for the bill. 2In spite of all the media hype, the truth is violence has decreased dramatically over the course of recorded human history.
1 I was called about an employee who had cut herself while on duty; her coworkers were understandably spooked.2A woman spun around at church a smacked a fellow worshiper with a hymnal.
The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment
plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate
educational resources.• Invite me to call you with any additional
questions I may have.• Make a follow up appointment.• Communicate with my other physicians.
• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some
routine demographic questions.• Ask me to list all of my problems and
concerns.• Using my problem list as a guide, ask me
clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status
examination.
1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Where can you find evidence-based information about mental disorders?
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.