A 38-year-old man was brought to the emergency department after nearly being hit by a car that swerved to avoid hitting him as he walked down the middle of a busy city street. On arrival, the patient was ataxic and his speech was slurred. He had evidence of polysubstance abuse on toxicology testing. He received intravenous fluids and was monitored for several hours in the emergency department. The patient's vital signs are now stable. He is oriented to time, place, and person, and he feels badly about his behavior. As the patient is about to be discharged, his wife arrives. He informs the staff that he does not wish to see her. Before the staff can intervene, she bursts into his room and they begin a heated argument about his substance use, recent job loss, and neglect of family responsibilities. The nurse asks the patient's wife to leave, but she says, "I'm not leaving. He is going to hear everything I have to say!" The patient becomes increasingly agitated and starts shouting. His fists are clenched and his loud voice and offensive language disrupt nearby staff and patients. Which of the following is the most appropriate next step in management?

Question

A 38-year-old man was brought to the emergency department after nearly being hit by a car that swerved to avoid hitting him as he walked down the middle of a busy city street.  On arrival, the patient was ataxic and his speech was slurred.  He had evidence of polysubstance abuse on toxicology testing.  He received intravenous fluids and was monitored for several hours in the emergency department.  The patient's vital signs are now stable.  He is oriented to time, place, and person, and he feels badly about his behavior.  As the patient is about to be discharged, his wife arrives.  He informs the staff that he does not wish to see her.  Before the staff can intervene, she bursts into his room and they begin a heated argument about his substance use, recent job loss, and neglect of family responsibilities.  The nurse asks the patient's wife to leave, but she says, "I'm not leaving.  He is going to hear everything I have to say!"  The patient becomes increasingly agitated and starts shouting.  His fists are clenched and his loud voice and offensive language disrupt nearby staff and patients.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: This patient is ready for discharge but becomes agitated when unexpectedly confronted with his angry spouse. The priority in this situation is to protect the patient, his wife, and the staff from violent acts. Initial management should involve nonpharmacologic interventions. Separating the patient from his wife would be the best initial step. Hospital security should be called to ask the patient's wife to leave (and escort her outside if necessary). If the patient becomes increasingly agitated and threatening despite her removal, then medication to calm him should be considered. Physical restraints are typically necessary for administering intramuscular medication or for patients who are at risk for harming themselves or others despite adequate medication. Safety in the emergency department requires the presence of adequate security personnel and protocols for managing agitated patients and visitors. Hospital security should be used in situations that may escalate quickly and that require prompt action to protect staff and other patients. Medications (benzodiazepines and antipsychotics) should be reserved for situations in which nonpharmacologic interventions fail to de-escalate an agitated patient. (Choice A) Chemical restraints should be implemented only if other strategies to defuse the situation fail or there is imminent risk of violence. In this case, a show of force by security and separating the patient from his wife would be the best next step. (Choice B) This situation is escalating rapidly and the wife has already refused to leave when asked by the nurse. In the interest of safety, it would be best to separate them immediately. The wife should not be encouraged to return, as her presence is a cause of his agitation. (Choice D) Discharging the patient in an agitated state is inappropriate and increases the risk of potential violence. (Choice E) It would be unsafe to have a social worker attempt to de-escalate this situation without security present. Prior to discharge from the emergency department, a social worker may counsel a receptive patient (and the patient's spouse with the patient's permission) about community support and resources for substance use treatment. Educational objective: Ensuring the safety of patients and staff in the emergency department is essential for effective patient care. This requires the presence of adequate security personnel and protocols for managing agitated patients and visitors. Medications (benzodiazepines and antipsychotics) are reserved for situations in which nonpharmacologic interventions fail to de-escalate an agitated patient. References: Workplace violence in emergency department and its effects on emergency staff. (http://www.ncbi.nlm.nih.gov/pubmed/25585480) The assessment and management of the violent patient in critical hospital settings. (http://www.ncbi.nlm.nih.gov/pubmed/23260370) A systematic review of the literature: workplace violence in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/20846214)

A 38-Year-Old Man Was Brought to the Emergency Department After