Journal of Health Care Communications Open Access

Patient Agitation and Violence in Medical-Surgical Units at a Large Inner-City Community Health Center in New York, One Year Before and During the COVID-19 Pandemic

Soroush Pakniyat-Jahromi, Jessica Bucciarelli, Souparno Mitra, Neda Motamedi, Ralph Amazan, Samuel Rothman, Vicente Liz^*, Jose Tiburcio and Douglas Reich Department of Psychiatry and Family Medicine, BronxCare Health System, USA
^*Correspondence: Vicente Liz, Department of Psychiatry and Family Medicine, BronxCare Health System, USA, Email:

Received: 26-May-2023, Manuscript No. IPJHCC-23-16568; Editor assigned: 29-May-2023, Pre QC No. IPJHCC-23-16568 (PQ); Reviewed: 12-Jun-2023, QC No. IPJHCC-23-16568; Revised: 19-Jun-2023, Manuscript No. IPJHCC-23-16568 (R); Published: 26-Jun-2023, DOI: 10.36846/2472-1654-8.3.8022

Introduction

Violence is an act of physical force intended to cause harm and may lead to physical and/or psychological damage. Violence toward healthcare workers (HCWs) is more common in psychiatric settings, emergency departments and nursing homes [1]; however, HCWs in a medical setting are not spared from such events. Workplace violence has a grave burden on the healthcare industry and has a major impact on staff’s physical and mental well-being.

The World Medical Association has most recently defined violence against health personnel as “an international emergency that undermines the very foundations of health systems and impacts critically on patient’s health” [2]. Globally there has been a reported increase in violence against HCWs, which had been noted even prior to the Pandemic [3]. A 2019 systematic review found that 61.9% of HCWs experienced a form of violence in the past year, verbal abuse being the most common, and 24.4% of HCWs experienced physical violence [4]. Since COVID-19, it has continued to worsen, with over 611 incidents reported to the International Committee of the Red Cross (ICRC) within the first 6 months of the Pandemic [5].

The purpose of this study is to compare the prevalence of patient agitation and violence in medical-surgical settings of a community hospital within a major urban area-BronxCare Hospital (BCH), Bronx, New York-one year before and during the COVID-19 Pandemic (03/2019-03/2020 and 03/2020-03/2021).

Methods

Prior to the initiation of the study procedures, it was approved by the Institutional Review Board (IRB # 06 10 21 01). Data collection occurred between June 2021 and August 2021, while the sampling time was from 2019 to 2021. The data were separated into two-time categories: Pre-COVID-19 (03/2019- 03/2020) and COVID-19 (03/2020-03/2021). The data required to be cleaned after collection, ensuring all patients were viable for the study. Patients that were not viable were excluded from the study. Four exclusion criteria were determined:

• Subjects under 18 years old;

• Agitation or violence related to substance use or withdrawal from substances or certain medications such as benzodiazepines;

• Agitation due to delirium and dementia;

• Verbal agitation and threats that were redirected and managed without the use of restraints or medications.

Due to the broad nature of different admission diagnoses, similar diagnoses were grouped by body systems. For example, seizure disorder was grouped into the Central Nervous System (CNS) disorders. Psychiatric diagnoses were grouped based on the underlying nature of the diagnosis.

We created frequency tables for 19 variables. Categorical variables were summed into frequency and percentages, but numerical variables, such as length of stay, were used to calculate mean, median, standard deviation, minimum, and maximum. We used a chi-square test to determine a variable’s statistical significance. We tested all variables against ‘Restraint Type’, determining if a patient was violent or became violent enough to restrain. The ‘Restraint types’ were Chemical, Physical, or Both. This analysis was also used to determine if there was a statistical difference between the pre-COVID-19 and during COVID-19 timeframe.

Results

The sample size for the pre-COVID-19 population was n=115, while the sample size for the COVID-19 timeframe was n=194. The ratio between age groups remained the same for both timeframes. During COVID-19, there was an increase in female patients (n=65, 33.5%) and a decrease in male patients (n=129, 66.5%). There was an increase in Asian (n=27, 13.9%) and Latino/Hispanic (n=63, 32.5%) patients between the two timeframes. Table 1 illustrates a detailed demographic data comparison between pre-COVID-19 and COVID-19 eras.

Table 1: Descriptive statistics on sample population demographics

The top admission diagnosis for pre-COVID-19 and COVID-19 timeframes was CNS disease. Table 1 shows the main admission diagnoses in both timeframes. Psychotic disorders were the top psychiatric background in both pre and during- COVID-19 timeframes. There was no significant change in substance use history during both timeframes (Table 2). There was a slight increase in 30-day and 90-day readmission rates during COVID-19 (n=33, 17%), (n=19, 9.8%). Medicaid remained the most common health insurance type pre-and during COVID-19. Haldol was the most frequently used medication for agitation management pre-and during COVID-19.

Table 2: Drug information pre and during Covid

We used a 95% significance threshold, p=0.05. Several variables were statistically significant pre-COVID-19: Age (p=0.02), race/ethnicity (p=0.01), header for violence (p=0.002), number of chemical restraints throughout admission (p=0.001), insurance status/type (p=0.02), and intra-muscular (IM) medications (p=0.05) (Table 3a).

Table 3a: Pre-covid variables those are statistically significant as predictors of violence

Variables that were statistically significant during-COVID-19: Race/ethnicity (p<0.001), substance use history (p<0.001), urine toxicology completion (p=0.04), header for violence (p=0.007), length of stay (p=0.05), number of chemical restraints throughout admission (p<0.001), insurance status/type (p=0.002), and Intra-Muscular (IM) medications used (p=0.002) (Table 3b).

Table 3b: During Covid variables that are statistically significant as predictors of violence

There was overlap between some of the statistically significant variables, such as race, insurance status, and header for violence between the two study periods. Despite this overlap, variables such as race/ethnicity, number of chemical restraints throughout admission, insurance status/type, and intramuscular (IM) medications became more statistically significant from the pre-COVID-19 to during the COVID-19 era. However, the header for violence decreased in statistical significance from pre-COVID-19 to COVID-19 era. This could indicate that these patients did not have the header placed at the beginning of the admission because they were new violent patients, or that less attention was placed on the entry of the header in the electronic health record during COVID-19, despite the increased number of positive BVC results.

Our final analysis, completed using a chi-square test, determined the difference in violence in patients between pre- COVID-19 and COVID-19 era. We then tested the violence marker against restraint type. The result was statistically significant, p=0.01.

Discussion

This is the first paper to systematically review the prevalence of viole ce in medical-surgical units in a hospital, pre COVID-19 and during the COVID-19 era.

Our data shows that there was an increase of almost 70% in incidents of violence during COVID-19 (03/2020-03/2021) with total of 194 (62.8%) reported events, compared to pre COVID-19 (03/2019-03/2020) with 115 (37.2%) events (p=0.01).

Violence and its management in healthcare settings have traditionally been a challenge [6-10], and the COVID-19 pandemic has brought to bear the complexity of circumstances, which may have increased its incidence.

Our data aligns with the global trend of increased violence toward healthcare workers during the COVID-19 pandemic [11- 13].

While it remains unclear what effect the COVID-19 pandemic had on violence in healthcare settings, potential risk factors for violence could be categorized into three groups:

• Patient-related factors

• Healthcare worker-related factors

• Institutional-related factors

Below we will describe each group:

1. Patient-related factors:

• Financial stressors (e.g., unemployment, homelessness and food insecurity)

• Worsening substance use and mental health prior to admission

• Fear of becoming infected by COVID-19 during a hospital stay

• Visitor restrictions during the peaks of the pandemic

2. Healthcare workers-related factors

• Staff burnout affecting the quality of care

• Inadequate training on violence risk assessment, de-escalation techniques and other preventative measures

• Poor documentation of violent incidents

• Poor communication among healthcare workers regarding violent incidents

3. Hospital-related factors

• Limited preventative measures and focused policies that were misaligned with the early COVID-19 era

• Initial insufficient personal protective equipment leading to limited assessments

• Challenges in staffing (fewer nurses and nurse assistants)

• Inadequate video surveillance in common areas of the hospital

The Broset Violence Checklist (BVC) is a tool to assess for confusion, irritability, verbal and physical threats, and attacks on objects as either present or absent [14]. It is hypothesized that any patient presenting with two or more of these behaviors is more likely to be violent in the next 24 hours [14]. At Bronx- Care, BVC is used in the med-surg units for violence risk assessment. Data reported by the nursing department shows that about 1800 cases had positive BVC in 2019 while this number increased dramatically to about 4100 in 2020. Unfortunately, our data cannot clarify what percentages of the patients with positive BVC were restrained either physically or chemically during their admission into med-surg units at BronxCare. We could however conclude that the COVID-19 pandemic has had a significant role in the BVC results.

Table 1 describes the demographic information of patients including age, gender and ethnicity. As shown, Black/African Americans suffered more incidents of violence followed by Latino/Hispanics; however, it is worth mentioning that the two ethnicities make up the main patient population at BronxCare; hence it cannot be concluded in our study that ethnicity is a risk factor for violence.

While it may be assumed that having a psychiatric comorbidity may increase the incidence of violence, in a study by Della et al., the diagnosis of a mental health condition was associated with a decrease in physical aggression and assault [9]. Our study also did not show any positive correlation between past psychiatric history and increase in the incidence of violence. In our study during the pre-COVID-19 era 83.5% of cases of violence had a psychiatric diagnosis while in the COVID-19 era 71.1% of cases had psychiatric illness (Tables 3a and 3b).

The admission diagnosis for individuals with violence is reported in Table 1. The main admission diagnosis was seizure disorder, which was categorized under CNS diseases. Musculoskeletal diseases ranked second with Rhabdomyolysis being the main diagnosis. Chart review revealed that the Rhabdomyolysis cases were the result of multiple chemical restraints precipitated by violent behavior while admitted in the Psychiatric inpatient units at BronxCare hospital, who were in turn transferred to the medical units for treatment.

There was no significant difference in the median age for violence in pre-COVID versus the COVID era (S1) The median length of stay was also identical (4 days) in both periods, and the average length of stay in the hospital was less in the COVID-19 era (5.84 days) versus pre COVID-19 era (7.15 days).

Table 1 report that substance use history was a major risk factor for violence in med-surge units, and almost two-thirds of violence pre and during COVID had a history of substance use. Urine toxicology on arrival was done for most (almost 70%) but not all cases (Table 1), which is an area of improvement for the future (Figure 1).

Figure 1: Restraint type (chemical, physical, or both) versus pre and during Covid time frame

Communication among healthcare workers is key when dealing with hospital violence. A simple tool used on the EMR at Bronx- Care is to place a header for “violence” in the patient’s chart following a violence risk assessment or any violent events, which already happened. This serves as an alert to warn staff about the potential risk for violence and the appropriate precautions required while caring for these patients. Only a few cases, both pre and during the COVID-19 pandemic, had the header for violence (Table 4), which indicates that better communication needs to occur amongst healthcare workers of different disciplines.

Table 4: Pre-covid versus during covid versus restraint type as a predictor of violence

Violence risk assessment should be improved, and all healthcare workers especially nursing staff, need to be fully trained not only for violence risk assessment but also for de-escalation and preventative techniques and improving interdisciplinary communication as well as adequate documentation.

Global changes in nursing practices and improvements in emergency management strategies have resulted in lower incidences of restraint use in the past decade [15]. In an Australian study, it was reported that there has been a recent focus on preventative measures such as de-escalation techniques as first-line management in dealing with violent patients to minimize the use of restraints and utilize them as a last resort [16]. Despite these efforts, there have been many reports of a rise in the prevalence of agitation, violence, and abuse in the healthcare sector, which threatens healthcare workers’ rights to a safe and harassment-free working environment and may indicate the need for improved strategies in dealing with violent patients [17-20]. Healthcare workers and stakeholders must review their strategies, policies and practice guidelines in order to make appropriate adjustments when significant events such as pandemics occur (Table S1).

Conclusion

Educating staff about de-escalation techniques has shown to be very effective, and more focus should be paid to prevention strategies to create a less restrictive environment to the delivery of care.

Updating policies and reviewing the protocols for safety in the healthcare system should be considered during future largescale events such as the Pandemic.

Our data can potentially improve the quality of care and safety for healthcare workers and patients by using preventative approaches and the least restrictive measures when dealing with agitated patients.

Limitations

Our inclusion criteria for violence in the study only captured cases that led to physical restraints or required IM medications. The staff’s experience in dealing with violent patients is not uniform, which may result in bias in the data.

Our data collection was from 03/2019 to 03/2020 for the pre- COVID-19 and from 03/2020 to 03/2021 for the COVID-19 era. This is while COVID cases were reported a few months earlier, in January 2020. We targeted the World Health Organization (WHO) date of 03/2020 as the start of the pandemic for our data collection to better capture the psychosocial aspects of COVID-19 leading to violent events in med-surg units, however, this time discrepancy may have resulted in bias in the data collected.

Declarations

Findings

This is the first paper to systematically, and retrospectively review the prevalence of violence in medical-surgical units in a community hospital pre COVID-19 and during the COVID-19 era. Our data shows that there was an increase of almost 70% in incidents of violence during COVID-19 (03/2020-03/2021) with 194 (62.8%) reported events, compared to pre COVID-19 (03/2019-03/2020) with 115 (37.2%) events (p=0.01).

Meaning

Our data can potentially improve the quality of care and safety for healthcare workers and patients by using preventative approaches and the least restrictive measures when dealing with agitated patients.

Statement

All authors have contributed sufficiently to the manuscript and all authors have approved the final manuscript.

Funding

No funding or sponsorship was received for this study.

Acknowledgement

None.

Conflict Of Interest

The authors declare no conflicts of interest.

References

1. Mento C, Silvestri MC, Bruno A, Muscatello MRA, Cedro C, et al. (2020) Workplace violence against healthcare professionals: A systematic review. Aggress Violent Behav. 51:101381.

   [Crossref] [Google Scholar]

2. World Medical Association 73^rd World Health Assembly, Agenda item 3: Covid-19 pandemic response. (2020)
3. McKay D, Heisler M, Mishori R, Catton H, Kloiber O (2020) Attacks against health-care personnel must stop, especially as the world fights COVID-19. Lancet. 395(10239):1743-1745.

   [Crossref] [Google Scholar]

4. Liu J, Gan Y, Jiang H, Li L, Dwyer R, et al. (2019) Prevalence of workplace violence against healthcare workers: A systematic review and meta-analysis. Occup Environ Med. 76(12):927-937.

   [Crossref] [Google Scholar]

5. Devi S (2020) COVID-19 exacerbates violence against health workers. Lancet. 396(10252):658.

   [Crossref] [Google Scholar]

6. Phillips JP (2016) Workplace violence against health care workers in the United States. N Engl J Med. 374(17):1661‐1669.

   [Crossref] [Google Scholar]

7. Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, et al. (2015) Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med. 58(11):1194‐1204.

   [Crossref] [Google Scholar]

8. Schablon A, Zeh A, Wendeler D, Peters C, Wohlert C, et al. (2012) Frequency and consequences of violence and aggression towards employees in the German healthcare and welfare system: A crosssectional study. BMJ Open. 2(5):e001420.

   [Crossref] [Google Scholar]

9. Derscheid DJ, Lohse C, Arnetz JE (2021) Risk factors for assault and physical aggression among medically hospitalized adult patients who had a behavioral emergency call: A descriptive study. J Am Psychiatr Nurses Assoc. 27(2):99-110.

   [Crossref] [Google Scholar]

10. Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C (2020) Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis. J Psychiatr Ment Health Nurs. 27:425-445.

    [Crossref] [Google Scholar]

11. Sakthivel P, Rajeshwari M, Malhotra N, Ish P (2020) Violence against doctors: An emerging epidemic amidst COVID-19 pandemic in India. Postgrad Med J. 98(e2):e74.

    [Crossref] [Google Scholar]

12. McGuire SS, Gazley B, Majerus AC, Mullan AF, Clements CM (2022) Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med. 53:285.e1-285.e5.

    [Crossref] [Google Scholar]

13. Rodríguez-Bolaños R, Cartujano-Barrera F, Cartujano B, Flores YN, Cupertino AP, et al. (2020) The urgent need to address violence against health workers during the covid-19 pandemic. Med Care. 58(7):663.

    [Crossref] [Google Scholar]

14. Woods P, Almvik R (2002) The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl. 106(Suppl. 412):103-105.

    [Crossref] [Google Scholar]

15. McSherry B (2017) Regulating seclusion and restraint in health care settings: The promise of the convention on the rights of persons with disabilities. Int J Law Psychiatry. 53:39-44.

    [Crossref] [Google Scholar]

16. Gerace A, Muir-Cochrane E (2019) Perceptions of nurses working with psychiatric consumers regarding the elimination of seclusion and restraint in psychiatric inpatient settings and emergency departments. Int J Ment Health Nurs. 28(1):209-225.

    [Crossref] [Google Scholar]

17. Hu F, Muir-Cochrane E, Oster C, Gerace A (2019) An examination of the incidence and nature of chemical restraint on adult acute psychiatric inpatient units in Adelaide, South Australia. Int J Ment Health Nurs. 28(4):909-921.

    [Crossref] [Google Scholar]

18. Osteinelli EG, Jajawi S, Spyridi S, Sayal K, Jayaram MB (2018) Aripiprazole (intramuscular) for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev. 1(1):CD008074

    [Crossref] [Google Scholar]

19. Tangu K, Ifeanyi A, Velusamy M, Dar S, Shah N, et al. (2017) Knowledge and attitude towards pharmacological management of acute agitation: A survey of psychiatrists, psychiatry residents, and psychiatric nurses. Acad Psychiatry. 41:333-336.

    [Crossref] [Google Scholar]

20. Weiland TJ, Ivory S, Hutton J (2017) Managing acute behavioral disturbances in the emergency department using the environment, policies and practice: A systematic review. West J Emerg Med. 18:647-661.

    [Crossref] [Google Scholar]