Flagging’ disruptive patients reduces violence
Portland VA program cut incidents by 92%
A nurse reached into a car to help a man into the emergency department (ED) at the Portland (OR) Veterans Affairs (VA) Medical Center when suddenly, without warning or provocation, the man lashed out and punched her. As the nurse backed off, a colleague called the VA police.
Two police officers escorted the man into the ED, where he received a swift medical examination and was sent on his way.
For many hospitals, that scenario might end with no more than an injury report. But at the Portland VA, which has a system of tracking and responding to violent events, it triggered action by the Hospital Committee on Violence. This patient, suffering from withdrawal from prescribed narcotics he took for pain, was actually a regular at a VA clinic several hundred miles away.
Within days of the event, he received a letter by certified mail that informed him that such incidents in the future could result in the loss of health care privileges at the medical center.
"Those letters are very effective. We inform patients that we are looking at their behavior, and we aren’t going to tolerate continued episodes," says David Drummond, PhD, director of the mental health clinics at the Portland VA Medical Center and chair of the Hospital Committee on Violence and the Behavioral Emergency Committee.
Despite that tough-sounding language, the Portland VA doesn’t call its policy "zero tolerance." It is a part of the Coordinated Care Program that addresses patients with difficult, dangerous or drug-seeking behavior. The system flags and tracks violent incidents — and violent patients — and provides support and training to staff. Although the medical center rarely denies treatment, it alerts staff to high-risk patients.
A 1989 study of hospital violence before and after the program was introduced showed a 91.5% reduction in incidents.1 The hospital has been able to sustain the system and maintain the reduction in incidents, Drummond says.
That is particularly impressive when compared with the track record of the hospital industry as a whole. In 1999, hospital workers suffered 2,637 nonfatal assaults, a rate of 8.3 assaults per 10,000 full-time employees — four times higher than the national average for all private-sector employers. This spring, the National Institute for Occupa-tional Safety and Health issued an informational document on violence in hospitals. (The web site is www.cdc.gov/niosh/2002-101.html.
When the Coordinated Care Program began, a survey showed that 23% of patients involved in dangerous incidents were responsible for 38% of the incidents. While violence may seem sudden and unpredictable, past abusive or violent behavior is one predictor.
That is why reporting is the cornerstone of the Portland VA’s program. The medical center has worked hard to remove subtle barriers to the reporting of violent incidents in the workplace.
"[Employees] want to view the incident as isolated; it’s really not a big deal," says Shirley L. Toth, RN, director of the Coordinated Care Program. "They have not had a problem [with the patient] in the past. But when we looked into it we found there is actually a pattern that emerged in the medical center over a period of time."
Even if the altercation is just verbal — involving threats, abusive language, or intimidation — staff fill out a "Dangerous Behavior Report." (See sample form.) This document isn’t placed in the patient’s medical record, but is reviewed by the Behavioral Emergency Committee.
"When a frontline worker takes the time to make a report, it is acted upon," Toth says. "That has done a lot to improve morale."
The committee interviews the staff involved in the altercation and determines what, if any, intervention is needed. For example, staff may receive additional training in handling difficult patients or situations. Staffing shortages or space constraints may be identified.
In the worst-case scenario, physical assault or repeated threatening or dangerous incidents, patients may be "flagged" using an electronic flagging system. Whenever a patient’s name comes up in the registration process, an advisory appears on the computer screen and emits a soft tone.
Those flagged patients then receive kid-glove treatment. They may be moved ahead of other waiting patients in the ED so they can be discharged more swiftly. VA police may stand by outside the room during the medical examination. The patients may be checked for possession of weapons.
Flagged patients aren’t restricted in their use of health care services. "It doesn’t deter any kind of care that the patient needs and is entitled to," Toth says. But it gives nurses, physicians, and clerks some forewarning that they are dealing with a patient who has the potential for difficult or dangerous behavior.
The flagging works. In the second quarter of 2002, there were 76 ED visits by flagged patients. (EDs are the site of the highest rate of violent incidents in hospitals.) Only two incidents of disruptive behavior were reported during that time.
"We are virtually eliminating violence in those people we identify," Drummond says. "We know who the high-risk people are. We can handle them."
The flags are reviewed every two years. If there have been no further significant incidents, the flag may be lifted.
In some rare cases — particularly if the incidents involved weapons — a flagged patient may actually be banned from all but emergency care at the medical center. In those cases, the safety of the staff, other patients, and visitors takes precedence.
When Portland VA Medical Center began flagging repeatedly disruptive patients, Drummond and his colleagues worried that the action might be overly stigmatizing.
"This was unfamiliar territory," he says. "We were trying to weigh the rights and safety of other patients and employees with the right of patients to get care."
The emphasis has always been on providing appropriate care — not denying care. "This approach is not punitive," he says. "It is focused on safety and helping patients get health care. And helping employees not feel so helpless in a case where patients are literally terrorizing a whole institution."
Response to the program has been positive, and it has been implemented at VA medical centers around the country. Drummond and Toth also present the program to private hospitals.
The comprehensive nature of the program contrasts with piecemeal approaches to reducing violence. For example, metal detectors at the ED entrance of hospitals may filter out knives and guns. But a violent incident may involve a nontraditional weapon: a cup of steaming-hot coffee or a chair.
The Behavioral Emergency Committee also helps staff diffuse nonviolent but disturbing behavior. For example, when a patient with obsessive-compulsive disorder called the medical center’s care line 156 times in 154 days, the staff became frustrated and the patient seemed increasingly upset.
"We gave him a plan that said you can call on Sundays and Thursdays. He thought that was great," says Drummond. "It decreased the number of calls, but he still felt connected."
Ironically, the flagged patients often revel in the negative attention. "I think some of them, if they could, would wear a T-shirt that says, I’m flagged at the VA,’" says Drummond. "They feel somehow special because they get this special attention when they come into the emergency room."
[Editor’s note: For more information on the Coordinated Care Program, contact Shirley Toth at (503) 402-2962 or [email protected] or David Drummond at [email protected].]
Reference
1. Drummond DJ, Landy FS, Gordon GH. Hospital violence reduction among high-risk patients. JAMA 1989; 261:2,531-2,534.
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