AMA Recommends Strategies to Reduce Violence in ED

A resource document outlining essential services necessary to address emergency department violence was approved at last month's meeting of the AMA House of Delegates.

The document, in the form of a report by the AMA's Council on Science and Public Health (CSAPH), is designed to assist in the implementation of procedures to protect physicians and other staff in emergency departments (EDs) and to assure optimal care for patients, including those with psychiatric or behavioral conditions. The AMA will make it available to hospitals, emergency medicine departments, physicians, mental health clinicians, patient advocates, and law-enforcement organizations.

Child psychiatrist Louis Kraus, M.D., vice chair of the Section Council on Psychiatry and a member of the CSAPH who helped write the report, told Psychiatric News that care and management of patients with psychiatric illness is a critical focus of the document. “The report emphasizes—and a number of people testified in hearings on the document—that psychiatric patients who are appropriately medicated are no more likely to be violent than the general population,” Kraus said.

The report notes that hospital EDs are treating an increasing number of patients with mental and substance use disorders because of the decline in availability of federal-, state-, and community-funded services.

The report also draws attention to APA's Practice Guideline for the Psychiatric Evaluation of Adults, which describes specific approaches for the emergency evaluation of psychiatric patients. The AMA report also notes that a monograph available on the APA Web site titled Safe MD discusses practical applications and approaches to safe practices including those recommended for managing aggressive patients.

“Several patient characteristics that may increase the risk of aggression are noted, as are several tips for working safely with potentially dangerous patients,” according to the CSAPH report. “Use of a predetermined emergency department triage system or scale to ensure timely and appropriate treatment of patients who are very distressed, acutely psychotic, violent, or aggressive can be helpful. Where possible, EDs should have dedicated treatment rooms for psychiatric patients that avoid exacerbation of the patient's illness. Facilities with significant psychiatric presentations should consider hiring dedicated psychiatrically trained staff.”

The CSAPH report examines data on the occurrence of violence in the ED, explains current standards that apply to workplace safety and security in hospital settings, and reviews recommendations of various organizations on how to mitigate violence in the ED, with some attention to handling patients with psychiatric conditions.

The CSAPH has for several years addressed some of the issues most important to psychiatry. A report on use of antipsychotic medication in children, which Kraus has been instrumental in writing, will be brought to the House of Delegates at the June 2011 meeting in Chicago, for example.

A CSAPH report on health programs for impaired physicians was also the subject of considerable debate at the November meeting, but was ultimately referred back to the CSAPH for reconsideration. That report gives an overview of the development and operation of physician health programs and addresses the barriers to use of these programs and the effectiveness of their confidentiality safeguards. It also recommends the following as essential components of a state-sponsored physician health program:

But in reference committee hearings, some delegates expressed concern that the report focused too exclusively on addiction without sufficiently addressing other issues relevant to physician impairment, including other psychiatric illness and the so-called “disruptive physician.”

Kraus, in an interview with Psychiatric News, said that disruptive behavior is not an uncommon reason for referring physicians for treatment, but is a problematic designation that can be misused. “It's not in the DSM, and hospital personnel can use this construct to discipline a physician who challenges the administration,” he said.

Other items that the CSAPH dealt with that were approved by the AMA include a report on health risks associated with the BP Gulf oil spill and resolutions on possible rescheduling of medical cannabis, return of children and adolescents to play or sports practice following a concussion, and improved residency training on the care of gay and transgender patients.

The reports on ED violence and physician health programs as well as other items addressed by the CSAPH are posted at <www.ama-assn.org/ama/pub/meeting/reports-resolutions.shtml>.