Evidence Summary: Interventions to Address and Prevent Violence Toward Health Care Workers in the Emergency Department


( Last Updated : August 26, 2021)

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Key Messages

  • Findings were inconsistent regarding education and training interventions for preventing violence in the emergency department. Most findings from relevant primary studies found no difference in the occurrence of violence. A few primary studies reported a reduction in the occurrence of violence; however, statistical significance of the difference was not reported. It is possible that the inconsistencies in these findings may be due to variations in education and training.
  • Pharmacological interventions with haloperidol, lorazepam, droperidol, risperidone, olanzapine, or quetiapine were effective in reducing aggressive behaviour and side effects were generally minimal.
  • Implementation of restraint documentation tools was associated with a decrease in the use of physical restraints to manage aggressive behaviours. When physical restraints were used for a short duration, complications were minimal.
  • No evidence-based guidelines were identified.
  • The systematic reviews identified had a broad focus. The included studies within the systematic reviews that were relevant for this report were few and generally of low quality. There was also a lack of details regarding the characteristics of the population within the studies. Therefore, these findings need to be interpreted with caution; more research is needed.

Context

The prevalence of workplace violence (WPV) in the health care setting is increasing and has detrimental consequences for the health care worker, the patient, and the organization. Emergency departments are considered high-risk areas, with high incidences of violence against health care workers being reported (with a range of between 60% and 90%). Few affected people report WPV and fewer seek help. Causes of violence and aggression vary and are not always clear. Common causes include distress and frustration, physiologic imbalances, substance misuse and abuse, intoxication, and mental health issues. WPV may result in physical injury and mental stress to the health care worker, which could lead to absenteeism, staff turnover, decreased productivity, and compromised care.

Technology

Various interventions can be implemented to prevent the violence experienced by health care workers in the emergency department. These interventions include education and training programs, various pharmacological interventions, and physical restraint procedures.

Issue

Violence toward health care workers in the emergency department is a longstanding problem that has reportedly worsened during the COVID-19 pandemic. A review of the clinical effectiveness evidence, and a review of evidence-based guidelines regarding the interventions for the prevention of violence toward health care workers in the emergency department, is needed to make informed decisions regarding the implementation of preventive measures.

Methods

A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results

The clinical evidence from 7 systematic reviews was summarized. No evidence-based guidelines were identified.

Table 1: Non-Pharmacological Interventions to Prevent Violence in the Emergency Department Evidence Summarya

Systematic reviewb

Intervention

Outcome

Results

Studies within the systematic review that contributed to the results summarized

Geoffrion et al. (2020)1

Face-to-face feedback and discussion of violent events

Risk of episodes of aggression

No statistically significant reduction

1 relevant cluster RCT

Spelten et al. (2020)2

Multimodal intervention that included education and training

Episodes of aggression

Inconclusive

1 pre- and post- intervention study

Raveel and Schoenmakers (2019)3

Training (and modifications
in emergency department physical structure and security, and policy changes)

Physical assaults against physicians, acquiring knowledge for handling violent situations

No reduction in assaults, increased knowledge and confidence to handle violence (statistical significance not reported)

1 review article

Structured feedback program

Acquiring knowledge for handling violent situations

Better awareness of risk assessment and how to deal with aggressive patients (statistical significance not reported)

Randomized controlled trial

Raveel and Schoenmakers (2019)3

Mechanical restraints

Complications

Minimal when used for short durations (statistical significance not reported)

1 systematic review

d’Ettorre et al. (2018)4

Training based on lectures compared to interactive and dynamic learning methods

Preventing workplace violence

Lectures were less effective than interactive and dynamic learning methods

1 study (type of study not reported)

Weiland et al. (2017)5

Education and dialogue

Violent behaviour

Reduction in violent behaviour (statistical significance not reported)

1 pre- and post- intervention study

Multimodal intervention that included education and training

Assault rates

Decreases in both the intervention and control groups (statistical significance not reported)

1 controlled quasi- experimental study

Implementation of restraint documentation tools

Restraint use

Decrease (findings from a narrative synthesis)

2 pre- and post- intervention studies

Ramacciati et al. (2016)6

Multimodal interventions that included education and training

Assault rates

Inconclusive results

1 quasi- experimental study and 1 review article

Gaynes et al. (2016)7

Multimodal interventions including staff training

Seclusion and restraint episodes

Decrease (statistical significance not reported)

2 pre- and post- intervention studies

Table 2: Pharmacological Interventions to Prevent Violence in the Emergency Department Evidence Summarya

Systematic reviewb

Intervention

Outcome

Results

Studies within the systematic review that contributed to the results summarized

Raveel and Schoenmakers 20193

Medication (not specified)

Aggressive patient behaviour

Reduces the incidence (statistical significance not reported)

1 systematic review

Gaynes et al. (2016)7

Haloperidol plus lorazepam when compared to lorazepam

Aggressive behaviour

Statistically significant improvements at 60 minutes, statistically significant

shorter time until improvement in behaviour, and no medication adverse effects

1 randomized controlled trial

Droperidol when compared to lorazepam

Combative and aggressive behaviour

Statistically significant decrease when assessed
up to 60 minutes after administration (longest time point assessed in study)

1 randomized controlled trial

Risperidone, olanzapine, quetiapine, and haloperidol

Aggressive behaviour

Improvements
from baseline up
to 72 hours post- administration; there were no between- group differences found (statistical significance not reported) and few adverse effects

1 non-randomized study

 

References

  1. Geoffrion S, Hills DJ, Ross HM, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020;9:CD011860.
  2. Spelten E, Thomas B, O’Meara PF, Maguire BJ, FitzGerald D, Begg SJ. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database Syst Rev. 2020;4:CD012662.
  3. Raveel A, Schoenmakers B. Interventions to prevent aggression against doctors: a systematic review. BMJ Open. 2019;9(9):e028465.
  4. D’Ettorre G, Pellicani V, Mazzotta M, Vullo A. Preventing and managing workplace violence against healthcare workers in emergency departments. Acta Biomed Ateneo Parmense. 2018;89(4-S):28-36.
  5. Weiland TJ, Ivory S, Hutton J. Managing acute behavioural disturbances in the emergency department using the environment, policies and practices: a systematic review. West J Emerg Med. 2017;18(4):647-661.
  6. Ramacciati N, Ceccagnoli A, Addey B, Lumini E, Rasero L. Interventions to reduce the risk of violence toward emergency department staff: current approaches. Open Access Emerg Med. 2016;8:17-27.
  7. RTI-UNC Evidence-based Practice Center, Gaynes BN, Brown C, et al. Strategies to de-escalate aggressive behavior in psychiatric patients. (Comparative effectiveness review no. 180). Rockville (MD): Agency for Healthcare Research and Quality; 2016: https:// effectivehealthcare.ahrq.gov/products/aggression/research. Accessed 2021 May 18.