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Beware the Emergency Department - Part 1

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This article will look at the guidance provided on the management of patients who are violent in the setting of an Emergency Department (ED).  Most assaults in hospital occur within the ED; the overall reported figures for violent attacks against all NHS staff show over 68,000 incidents for 2013 -14.

A follow on article next week will describe different medication and restraint techniques that can be used, but it is important to note that these should be used sparingly as the following recommendations produced by NICE (National Institute for Clinical Excellence Guidelines) are aimed at reducing the need for such steps. Preventing violent situations from developing – e.g. by defusing the situation, or having expert help in place such as a mental health team – may help substantially.

Features that lead to violence

  • The patient’s personality and degree of mental distress
  • Attitudes and behaviour of staff
  • The physical setting, including any restrictions on the patient’s perceived freedom

In providing recommendations, NICE suggest the use of graded interventions to stop the development of violence taking place.

Anticipating and reducing the risk of violence and aggression

Staff training should have a person centred focus to promote a therapeutic relationship and to comprehend the nature of the relationship between mental health problems and the risk of the development of violent behaviour.

The following skills should be taught:

  • To assess why behaviour is likely to become violent or aggressive, including personal, constitutional, mental, physical, environmental, social, communicational, functional and behavioural factors
  • To understand and be able to apply methods and techniques to reduce or avert imminent violence and defuse aggression when it arises (for example, verbal de-escalation) skills, methods and techniques to undertake restrictive interventions safely when these are required
  • To undertake an immediate post-incident debrief
  • To undertake a formal external post-incident review in collaboration with experienced service users who are not currently using the service

Managing violence and aggression in emergency departments:

Healthcare providers and commissioners should:

1.         Ensure that every ED has routine and urgent access to a multidisciplinary liaison team that includes consultant psychiatrists and registered psychiatric nurses who are able to work with children, young people, adults and older adults.

2.         Ensure that a full mental health assessment is available within 1 hour of alert from the ED at all times.

3.         Train staff in EDs in methods and techniques to reduce the risk of violence and aggression, including anticipation, prevention and de-escalation.

4.         Train staff in mental health triage.

5.         Train staff to distinguish between excited delirium states (acute organic brain syndrome), acute brain injury, and excited psychiatric states (such as mania and other psychoses).

6.         Ensure that, at all times, there are sufficient numbers of staff on duty who have training in the management of violence and aggression in line with this guideline.

7.         Undertake mental health triage for all service users on entry to the ED - alongside physical health triage.

8.         Ensure that EDs have at least 1 designated interview room for mental health assessment that: is close to or part of the main ED receiving area; is made available for mental health assessments; as a priority can comfortably seat 6 people; and that is fitted with an emergency call system, an outward opening door and a window for observation contains soft furnishings and is well ventilated contains no potential weapons.

Staff interviewing a person in the designated interview room should inform a senior member of the emergency nursing staff before starting the interview to make sure another staff member is present.

If a service user with a mental health problem becomes aggressive or violent, do not exclude them from the emergency department.

Regard the situation as a psychiatric emergency and refer the service user to mental health services urgently for a psychiatric assessment within 1 hour.

The next article on the management of violence in EDs will focus on the use of rapid administration of medication and the use of physical restraint techniques. However, it must be emphasised that the prevention and de-escalating of violence is of the highest priorities.


Staff and patients do suffer from injury caused by violent episodes occurring in the ED setting. Ensuring that the above recommendations have been taken into account will be helpful to determine if all the necessary steps were in place at the time of the incident.  Claims may come from patients (or their relatives / representatives), or from staff who have been affected by an episode of violence.  This is a helpful checklist to ensure that any Trust which faces such a claim, cannot be accused of having been negligent in their duty of care.


If you want further information about this particular topic, or wish to discuss the possibility of bringing a claim for Clinical Negligence - or indeed any other type of injury, please contact the Dutton Gregory Clinical Negligence Team on (01202) 315005, or email  

NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory, solicitors. .