Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation-Enhanced Interprofessional Curriculum.

Ambrose Wong,Maureen Gang,Lisa Wing,Brenda Weiss

doi:10.5811/westjem.2015.8.26220

Abstract

IntroductionWhile treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design.MethodsFormal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs.ResultsOne hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training.ConclusionA structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

Highlights

Introductionemergency department (ED) have been identified as high-risk settings for workplace violence (WPV).[3] A national survey of emergency physicians found that at least one WPV act was reported in 78% of all responders, and 21% reported more than one episode.[4] Several studies have shown that emergency nurses are at the greatest risk of experiencing verbal and physical assault as compared to nurses in other healthcare settings and to physicians.[5,6] Precipitators of violence and aggression in the ED are most commonly attributed to alcohol/substance abuse, mental illness, and altered perceptions and confusion, all of which frequently exist in agitated patients.[7,8] Management of acutely agitated patients consists of physical restraints and administration of appropriate medications and utilization of de-escalation and agitation reduction techniques.[2,9]
While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury
Staff attitudes toward patient aggression have been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients

Summary

Introduction

EDs have been identified as high-risk settings for workplace violence (WPV).[3] A national survey of emergency physicians found that at least one WPV act was reported in 78% of all responders, and 21% reported more than one episode.[4] Several studies have shown that emergency nurses are at the greatest risk of experiencing verbal and physical assault as compared to nurses in other healthcare settings and to physicians.[5,6] Precipitators of violence and aggression in the ED are most commonly attributed to alcohol/substance abuse, mental illness, and altered perceptions and confusion, all of which frequently exist in agitated patients.[7,8] Management of acutely agitated patients consists of physical restraints and administration of appropriate medications and utilization of de-escalation and agitation reduction techniques.[2,9]

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Conclusion