A 3-year-old male and 4 year-old female came to a pediatric emergency room. At triage the mother was noted to be quite agitated. She refused to sit, rocked back and forth and was talking under her breath. Her answers didn’t make sense to the nurse, who became concerned about the mother and quickly moved the family into a room. The nurse called the senior resident who went to see the family right away. When the resident entered the room, the mother was standing against the wall and would rock or walk in small circles. The mother would answer questions briefly about the children, and then seemed to be carrying on a conversation with herself but specifics couldn’t be heard. When asked if she was feeling well, she became even more agitated. She said she wanted medicine for the children’s colds. The resident tried to ask again and the mother started move toward the resident in a threatening manner and then turned away. The children appeared well with rhinorrhea present and the mother was not being threatening towards them, so the resident left the room with the door open and quickly talked with the attending physician. Together the attending and resident went to see the family. The attending physician asked her again if she felt well and the mother became more agitated verbally. When asked if she had any medical problems or had taken any medications the mother denied it. She also denied any alcohol or drugs. It became clearer listening to the mother that she was talking to someone who was not present. When asked, the mother said that she was hearing a voice talking to her who was “making her angry” when she just wanted medicine for the children. She denied visual hallucinations. Initially the mother refused to have the children examined, but after some more talking, allowed the resident to do a screening examination. They had upper respiratory infections. Meanwhile the attending was arranging transfer to an adult emergency department which had emergency psychiatric consultation and facilities and the Department of Social Services. The attending also contacted family members that the mother wanted called. A psychiatric nurse and a plain-clothes security officer were called to the emergency department but were kept out of sight because of the risk of aggitating the mother. The triage nurse brought food and drink for the family but the mother lunged for it and threw it in the sink and garbage can saying that it was poisoned. The resident developed some rapport and was able to calm her down by taking the food away and staying in the room talking with her. The mother agreed to go in the ambulance with the children and the staff felt this was appropriate as she previously became threatening when attempts had been made to separate the children from her (i.e. taking them to the bathroom). It was also decided that the resident would also go because her presence seemed to have a calming effect on the mother and she could monitor the children. The plain-clothes security officer also went in the ambulance. The transfer was uneventful and the mother was admitted with the diagnosis of acute psychosis. Social services and family members who met at the adult emergency department arranged to place the children with the family members.
Workplace violence is defined by the Occupational Health and Safety Administration (OSHA) as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.” Social services and health care professionals are at high risk for workplace violence, with the numbers probably higher because of underreporting. In 2000 the Bureau of Labor statistics reported the following rates of injuries from violent acts and assaults. Rates are per 10,000 full-time workers
The Department of Justice has average annual rates of non-fatal violent crime from 1993-1999. Rates are per 1000 workers
OSHA lists several reasons for the increased risk including:
- "Health care and social service workers face an increased risk of work-related assaults stemming from several factors. These include:
- The prevalence of handguns and other weapons among patients, their families or friends;
- The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals;
- The increasing number of acute and chronic mentally ill patients being released from hospitals without follow-up care (these patients have the right to refuse medicine and can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others);
- The availability of drugs or money at hospitals, clinics and pharmacies, making them likely robbery targets;
- Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;
- The increasing presence of gang members, drug or alcohol abusers, trauma patients or distraught family members;
- Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients;
- Isolated work with clients during examinations or treatment;
- Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);
- Lack of staff training in recognizing and managing escalating hostile and assaultive behavior; and
- Poorly lit parking areas."
An impaired parent may be a potential threat not only to healthcare workers in the location, but also their children, the public and themselves.
An American Academy of Pediatrics clinical report outlines legal and ethical considerations when dealing with parents whose judgment is impaired by alcohol or drugs and also notes that they should be applicable for impairment due to any cause.
The report notes that there are several legal considerations which can be in conflict including:
- "the physican-patient relationship;
- the duty to act in the best interest and for the safety of the patient;
- the need to obtain informed consent;
- the importance of safeguarding patient confidentiality;
- the mandated reporting of suspected child abuse and neglect; and
- the duty as an employer and business owner to protect the safety of employees and visitors in the office."
A physician's first duty is to the patient and he/she should try to "...decrease the risk[s] by the least restrictive means[,]" attempting to deescalate the situation. This can be accomplished in several ways including moving the parent with or without the children to a private area as quickly as possible, talking with the parent, talking with other family members, obtaining alternative transportation such as a taxi, etc.. It may also mean utilizing child protection or law enforcement services as necessary to secure the safety of the children, health care professionals and the public.
Parents have a reasonable right to expect confidentiality but ensuring safety of people takes precedent over parent confidentiality (i.e. keeping a door open during discussions, separating the children from the parent, etc.) Health care providers must also act within the state laws for protection of children from suspected abuse and neglect and therefore with an impaired adult, child protection services usually is involved in some manner. An impaired parent is often not able to give treatment consent for their minor child, therefore non-emergent treatment usually is postponed until appropriate consent can be obtained. In the emergency room, the Emergency Medical Treatment and Active Labor Act (EMTALA) may require screening for emergency medical conditions and provision of treatment regardless of consent.
Overall, the case above was generally successful. The professionals attempted to deescalate the situation by recognizing it, moving the family to a room quickly, providing comfort items (i.e. food), and treating the family by a small number of professionals including having the resident assist in the transport. The professionals also tried to keep the door closed when possible for privacy and confidentiality but also balanced this against having the door open to monitor the mother and protect the children and health care professionals. Permission was obtained to contact family members, but social services was contacted without permission. The children were appropriately screened for an emergency condition in the pediatric emergency room. Had the professionals not been able to convince the mother to voluntarily transfer to the adult hospital, law enforcement may have been needed to protect the children and public.
Questions for Further Discussion
1. What are your procedures for an impaired parent situation?
2. What are your procedures for a workplace violence situation?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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U.S. Department of Labor Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for
Health Care & Social Service Workers
Available from the Internet at http://www.osha.gov/Publications/OSHA3148/osha3148.html (cited 9/30/11).
CDC/NIOSH. Violence. Occupational Hazards in Hospitals. 2002.
U.S. Department of Labor Occupational Safety and Health Administration. Workplace Violence Fact Sheet.
Available from the Internet at http://www.osha.gov/OshDoc/data_General_Facts/factsheet-workplace-violence.pdf (rev. 2002, cited 9/30/11).
Fraser JJ, McAbee GN, and Committee on Medical Liability, American Academy of Pediatrics. Dealing with the parent whose judgment is impaired by alcohol or drugs: legal and ethical considerations. Pediatrics. 2004:114;869-873.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients' is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients' culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D'Alessandro, MD
Professor of Pediatrics, University of Iowa Children's Hospital