Implementing Behavioral Screening Protocols to Reduce Violence in the Emergency Department

Abstract

Problem and Purpose: The opioid crisis and lack of mental health resources for patients are two leading causes of elevated levels of violence in the emergency department. As a result, a rise in patient aggressive behavior including verbal and/or physical attacks against emergency department staff has occurred. This increase in violence led to a new restraint protocol and a subsequent increase in restraint orders, though restraint use is not recommended evidence-based practice. The purpose of this quality improvement project was to implement a behavioral assessment protocol for identifying aggressive patient behaviors and reduce physical restraint use in the emergency department at a community hospital. Methods: The protocol was implemented through a quality improvement project using two behavior identification tools to reduce possible violent incidences against staff thus reducing restraint orders. A modified Dynamic Appraisal Situational Aggression was given to every patient in the emergency to self-identify potential aggressive behavior. The Violence Assessment Tool was completed by the nurse on patients when their score on the modified Dynamic Appraisal Situational Aggression was greater than three. Anytime the Violence Assessment Tool has to be completed, the nurse was required to evaluate the combined tool scores for level of risk. Risk reduction and de-escalation strategies were implemented based on the identified risk level. Results: The data reflects a successful implementation of the protocol with 95% of the emergency department nurses completing the protocol when required, along with patients completing the modified Dynamic Appraisal Situational Aggression at a rate of 98% upon intake. Analysis of the data’s clinical component reflects successful reduction of restraint orders from 27.5% to 1.5% percent. Conclusions: The project can be replicated across all departments in the hospital, specifically acute settings and mental health. Educating all new staff regarding the implementation protocol and the de-escalation methods is recommended. In addition, adding a flag to the electronic medical record to alert nurses that a patient completing the modified Dynamic Appraisal Situational Aggression has met the threshold and the completion of the Violence Assessment Tool is necessary. Both recommendations will allow for the results of the project to be sustained and replicated.