Risk factors for violence in an emergency department: Nurses' perspectives.

OBJECTIVE: Work-related violence remains a significant problem in healthcare settings, including EDs. Violence risk assessment tools have been developed to improve risk mitigation in this setting; however, incorporation of these tools into standard hospital processes remains scarce. This research aimed to explore nurses' perspectives on the Bröset Violence Checklist used in routine violence risk assessment and their recommendations for additional items. METHODS: Thirty nursing staff who used the Bröset Violence Checklist (BVC) as standard practice for 5 years participated in two focus groups where 23 violence risk factors were presented. Using multiple methods, participants were asked to select and elaborate from a pre-determined list what they considered most useful in violence risk assessment in respect to descriptors and terminology. RESULTS: Quantitative data showed most risk factors presented to the group were considered to be predictive of violence. Ten were regarded as associated with risk, and overt behaviours received the highest votes. The terms 'shouting and demanding' was preferred over 'boisterous', and 'cognitive impairment' over 'confusion'. Patient clinical characteristics and staff perceptions of harm, inability to observe subtle behaviour, imposed restrictions and interventions and environmental conditions and impact were also important considerations. CONCLUSIONS: We recommend that violence risk assessment include: history of violence, cognitive impairment, psychotic symptoms, drug and alcohol influence, shouting and demanding, verbal abuse/hostility, impulsivity, agitation, irritability and imposed restrictions and interventions. These violence risk factors fit within the four categories of historical, clinical, behavioural and situational.

Emergency department staff experiences of the Bröset Violence Checklist.

AIM: Work-related violence is a significant problem in healthcare settings and emergency departments are one of the highest at-risk locations. There have been significant challenges in identifying successful risk-mitigation strategies to reduce the incidence and impact of work-related violence in this setting. This research explores the perspectives of clinical staff who routinely use violence risk assessment to provide recommendations for improvements. DESIGN: This qualitative research used interviews of staff who routinely use of the Bröset Violence Checklist in an emergency department. The study was conducted in April 2022. METHOD: Interview transcripts were subjected to Thematic Analysis to explore participants' clinical experiences and judgements about the utility of the Bröset Violence Checklist. RESULTS: Eleven staff participated in semi-structured interviews. Participants described themes about the benefits of routine violence risk assessment and the influence of the subjective opinion of the scorer with respect to the emergency department patient cohort. Four categories of violence risk factors were identified: historical, clinical, behavioural and situational. Situational risks were considered important for tailoring the tool for context-specificity. Limitations of the BVC were identified, with recommendations for context-specific indicators. CONCLUSION: Routine violence risk assessment using the Bröset Violence Checklist was deemed useful for emergency departments, however, it has limitations. IMPACT: This study's findings offer potential solutions to reduce violence affecting front-line workers and practical processes that organizations can apply to increase staff safety. IMPLICATIONS: The findings produced recommendations for future research and development to enhance utility of the Bröset Violence Checklist. REPORTING METHOD: EQUATOR guidelines were adhered to and COREQ was used. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution was involved in this study.

Characteristics and outcome of patients transported by police to emergency departments under section 351 of the Mental Health Act 2014 (Vic).

OBJECTIVE: To determine characteristics, precipitating circumstances, clinical care, outcome and disposition of patients brought to the ED under section 351 (s351, police detention and transport) powers of the Mental Health Act 2014 (Vic) (MHAV). METHODS: This is an observational cohort study conducted in two metropolitan teaching hospitals in Victoria. Participants were adult patients brought to ED under s351 of the MHAV. Data collected included demographics, event circumstances, pre-hospital and ED interventions and outcome. Analyses are descriptive. RESULTS: The present study included 438 patient encounters. Median age was 34 years. In 84% of encounters (368/438) patients were co-transported with ambulance. The most common primary reason for detainment was suicide risk/intent (296/438, 67.6%) followed by abnormal behaviour without threat to self or others (92/438, 21%). In ED, parenteral sedation was administered in 11% (48/438). Physical restraint was applied in 17.6% (77/438). Psychiatric admission was required in 23.5% (103/438). In 63 cases, psychiatric admission was involuntary (14.4%). Most patients (297/438, 67.8%) were discharged home. A subset of patients had recurrent s351 presentations. Eighteen (5.6%) patients accounted for 22% (96/438) of all events. CONCLUSION: Most patients brought to ED under s351 of the MHAV had expressed intention to self-harm, did not require medical intervention and were discharged home. It could be questioned whether the current application of s351 is consistent with the least restrictive principles of the MHAV, especially as there is no apparent monitoring or reporting of the use of these powers. There were a concerning number of patients with multiple s351 events over a short period.

Development, implementation and evaluation of a process to recognise and reduce aggression and violence in an Australian emergency department.

OBJECTIVE: In 2018, we developed and implemented a novel approach to recognition and response to occupational violence and aggression (OVA). It included routine use of the Brøset Violence Checklist for all ED patients integrated with a score-based notification and response framework. The present study evaluated the impact of the new process on staff knowledge, perceptions and confidence regarding OVA in ED and the rate of security events related to OVA. METHODS: The present study was conducted in a metropolitan hospital ED in Australia. Evaluation was by online before and after survey of nursing staff, point prevalence study of risk classification and comparison of OVA-related events involving security in the year before implementation and the year after the programme was embedded. RESULTS: One percent of patients were assessed as high violence risk with a further 4% at moderate risk. The introduction of the Brøset Violence Checklist increased documentation of violence risk assessment. It also improved staff perception of organisational support and awareness of behaviours associated with the risk of violence. There was a statistically significant reduction in unplanned OVA-related security responses (relative risk 0.75, 95% confidence interval 0.62-0.89). There was also a statistically significant shift to proactive management through early detection and intervention (relative risk 2.22, 95% confidence interval 1.85-2.66). CONCLUSION: A process including routine OVA risk assessment and a notification and response framework reduced unplanned security events due to OVA and increased staff confidence in recognition and management of OVA. This approach may be suitable for use more broadly in ED.

Review article: inotrope and vasopressor use in the emergency department.

Shock is a common presentation to the ED, with the incidence of septic shock increasing in Australasia over the last decade. The choice of inotropic agent is likely dependent on previous experience and local practices of the emergency and other critical care departments. The relatively short duration of stay in the ED before transfer leaves little room for evaluating the appropriateness of and response to the agent chosen. Delays in transfer to inpatient facilities means that patients receive advanced critical care within the ED for longer, requiring initiation and titration of vasoactive agents in the ED. This article discusses the general concepts of shock and the indicators for inotrope and vasopressor use, revises the various agents available and reviews the current evidence for their use.