Recognizing and De-Escalating Potential Violence in the Urgent Care Center

Max Lebow, MD, MPH, FACEP, FACOEM
Medical Director
Reliant Immediate Care Medical Group
Member Board of Directors Urgent Care Association

Healthcare workplace violence is nothing new. According to the Bureau of Labor Statistics (BLS), from 2011 to 2018, there has been a 64% increase in reported violent episodes in healthcare settings. Violence against healthcare workers has been recognized nationally, as the Workplace Violence Prevention for Health Care and Social Service Workers Act of 2021 recently passed the U.S. House of Representatives and is now in the Senate .
Reports of physical violence against healthcare workers in our urgent care centers have increased recently. Whether from the stress of Covid-19, long waits due to healthcare staffing shortages, or a general reduction in respect and authority of our institutions in general, violent incidents have been escalating. This report aims to increase awareness and generate a conversation amongst urgent care leadership and staff on recognizing, preparing, and addressing potential violent episodes from our patients.

Recognizing the Signs of Potential Violence
As leaders in urgent care medicine, our primary responsibility is to keep patients and our staff safe. Giving them tools to recognize potential violence in our patients is an essential tool to achieve this goal. One tool to help healthcare workers recognize potentially dangerous situations developed by The Joint Commission has the acronym STAMP.  The risk signs include Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing.
 
Tools such as STAMP can help or staff be prepared and differentiate upset patients from those who pose a risk. Early intervention can bend the arc of violence and result in a safe outcome for both staff and the patient.

Mitigation of Risk from Potential Violence
Patients get angry for any number of reasons. The urgent care staff must be prepared for patients who represent a physical danger. There are steps that urgent care centers can take to help prevent violence before it occurs or mitigate its effects if it does.

• The exam room documentation area should be close to the door. Review each exam room set up to ensure that the examiner is between the patient and the door, not the other way around.

• If a patient is angry, enter the exam room accompanied by another staff member. Extra staff may be excused once the situation is de-escalated.

• Encourage staff who feel uneasy or frightened to leave the room promptly. The team needs to know that urgent care leadership encourages staff to use their best judgment. A polite excuse such as, “I’ll be right back,” or “I need to check your chart” if you have time, but if not, just leave.

• Consider a medical cause – Is the patient angry, or is there an underlying medical condition such as alcohol withdrawal, were delirium from medication?

• Never hesitate to call for help – from security or even 911. Unlike an emergency department, most urgent care centers do not have access to chemical or physical restraints for the strength of numbers. Get help when needed.

De-Escalation
Verbal de-escalation of angry or potentially violent patients is a process. While several steps are listed, the literature suggests that the process of de-escalation can be completed in less than five minutes.

• Apologize for the Wait – Delays before seeing the provider often make patients angry, a precursor to violent outbursts. The introduction is the first and best opportunity to connect with the patient. “I’m sorry it took so long, but I’m here for you now,” shows empathy and breaks barriers to begin your relationship.

• Stay Calm – Do not take it Personally – Patient outbursts often are directed toward caregivers. These can include insults, racial and ethnic slurs, and ridicule of medical skills. Providers must anticipate behavior and manage it with the same professionalism used to approach any patient with an unexpected medical condition.

• Direct conversation to Feelings – for example, the response to, “I could’ve died waiting for you,” is not to tell the patient they’re not dying, but rather a response such as, “I understand, but I’m here now to help. Tell me what’s going on”.

• Establish a dialogue – de-escalation frequently takes the form of a verbal loop in which the clinician listens to the patient, finds a way to respond that agrees with or validates the patient’s position, and then states what he wants the patient to do, e.g., sit down, lower his voice. The loop repeats as a clinician listen to the patient’s response.

• Begin setting clear limits – this process may seem like a negotiation, but in reality, this conversation reintroduces rules of conduct that will allow the urgent care visit to proceed.

Healthcare workplace violence is a fact. Preparing providers and all clinic employees to recognize the signs of impending violence and decrease risk is the best way to keep our patients and staff safe.