Patients with acute psychiatric symptoms often present at the Emergency Department triage.   “Psych patients” were referred to as one of the main protagonists of violent behaviour in the Emergency Department during our surveys.    Because of their unpredictable behaviour - often lashing out without displaying obvious signs of distress or frustration - these patients are assessed by staff as being extremely dangerous.

Patients with psychiatric illness can create serious problems for Emergency Departments, which often do not have the nursing or physician expertise to deal with psychiatric illness.  Psychiatric patients respond better to a special, therapeutic environment that is generally quiet and controlled.   Emergency Departments are not quiet and are not controlled.   EDs are the loudest and most chaotic departments in all of the hospital and do not offer the best environment for patients who are struggling to maintain control in the face of psychosis or dementia. If a hospital does not have an in-patient psychiatric service, a patient waiting for psychiatric  admission often waits in the ED for an extended period of time until a qualified professional can evaluate and admit the patient or locate a secondary referral source. Additionally, because of the decreasing availability of psychiatric resources, the use of EDs for medical clearance before individuals are jailed is on the increase, which contributes to the potential for violent patient behaviour in the ED 

Holleran, quoted in  Violence in the Emergency Department, Patricia B. Allen

It is well known that patients experiencing an acute psychotic episode or similar degree of arousal can be extremely difficult to manage, if they are attempting to cause harm to themselves or others. Training in de-escalation, conflict communications (such as the excellent Verbal Defense and Influence) and in appropriate physical intervention and restraint should help remedy this situation by improving the cooperation between team-members during an intervention, whether verbal or non-verbal.  Team effectiveness should increase through better coordination and technical control of the situation. ---------------------------------------------- Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training