Management approach of patients with violent and aggressive behaviour in a district hospital setting in South Africa

Aggressive and violent behaviour is very common in the hospital setting. Simple agitation may unpredictably progress to overt aggression and violence by any patient in the emergency centres (ECs). Aggressive behaviour often manifests in forms of verbally abusive language, verbal threats and intimidating physical behaviour. Violent behaviour comprises the intentional use of physical force or power, threatened or actual, against self (suicidal), or another (homicidal) or properties, group or community, that could potentially result in injuries, death, psychological harm or deprivation. Therefore, individuals with unusual agitation and aggression should be treated as an emergency in both the community and healthcare settings in order to mitigate the progression to physical violence. Whilst the incidence and prevalence of aggressive and violent behaviour are higher in individuals with an underlying mental disorder, substance use disorder or comorbid mental disorder and substance use disorder, other individuals can also present with these behaviours in the ECs. Therefore, the front-line clinicians must be knowledgeable and competent in managing patients with aggressive behaviour with a view to de-escalate the situation and preventing or curtailing violence. This paper presents an evidence-based approach for managing patients with aggressive and violent behaviour, including a review of the steps for admitting patients for assisted or involuntary care.


Introduction
The emergency centres (ECs), otherwise known as casualty, in hospitals serve as the entry point for the majority of individuals with new-onset or persistent violent and aggressive behaviour. Healthcare workers are often victims of violent and aggressive behaviours of their patients. However, there are limited evidence-based intervention strategies to guide the management of patients with aggressive and violent behaviour in acute hospital settings. 1 Violence and aggression comprise a wide range of behaviours or actions, which can potentially cause harm, hurt or injury by someone to another person. 2 Violent and aggressive patients have the intention to dominate another person; as such, they express anger, defensive behaviour, verbal abuse, derogatory remarks, threats or non-verbal gestures. 2 Patients can express a wide range of violent and aggressive behaviours in the ECs. Aggression is described as a disposition towards instilling fear or flight in another person. Aggression includes all acts of hostilities toward becoming violent. Verbal aggression is very common and ranges from angry outbursts, loud shouts and noises, to outright use of verbal threats without real physical harm. The patients' tone of voice can be a warning sign of imminent violence. According to the World Health Organization (WHO), violence is an intentional use of physical force or power, threatened or actual, against self, or another individual, group or community, that could potentially result in injuries, death, psychological harm or deprivation. 3 Violence can be directed at individuals or properties. Violence towards objects can occur through slamming of doors, hitting of furniture, setting properties on fire and a host of other things. Violence towards another person can occur through threatening gestures or direct attack on another person causing serious bodily injuries or forcing someone into compromising or undesirable actions such as rape or sodomy.

Incidence and prevalence of violence and aggression in hospital settings
Aggression and violence from patients are the commonest causes of workplace violence and have reached epidemic proportions worldwide. 4,5,6,7 According to the National Institute of Health and Aggressive and violent behaviour is very common in the hospital setting. Simple agitation may unpredictably progress to overt aggression and violence by any patient in the emergency centres (ECs). Aggressive behaviour often manifests in forms of verbally abusive language, verbal threats and intimidating physical behaviour. Violent behaviour comprises the intentional use of physical force or power, threatened or actual, against self (suicidal), or another (homicidal) or properties, group or community, that could potentially result in injuries, death, psychological harm or deprivation. Therefore, individuals with unusual agitation and aggression should be treated as an emergency in both the community and healthcare settings in order to mitigate the progression to physical violence. Whilst the incidence and prevalence of aggressive and violent behaviour are higher in individuals with an underlying mental disorder, substance use disorder or comorbid mental disorder and substance use disorder, other individuals can also present https://www.safpj.co.za Open Access Care Excellence (NICE), emergency departments and psychiatric units experience far more violence and aggression than any other healthcare settings. 2 Healthcare workers experience a wide range of violence from patients and/or family members or guardians whilst performing clinical duties.
Verbal assault has been the predominant form of violence reported by the majority of healthcare workers and ranged from 58.0% in Australia to 100.0% in Brazil. 7 Significantly more female healthcare workers and specifically nurses (82.0%) have experienced more verbal abuse from their patients than their male counterparts. Nurses are three times more likely to experience aggressive and violent patient events whilst performing their duties. 2 Between 35.0% and 80.0% of healthcare workers have experienced physical assault at least once in their practice. In addition, psychological assaults range from 32.2% in Europe to 67.0% in Australia. 7 Men are the main perpetrators of physical threats (63.0%) and assaults (52.0%) against the healthcare workers. 5 Violence and aggression in the hospital setting reflect the broader complex dynamics of violence in the general South African communities. Mahlangu et al. 6 reported 66.7% of healthcare workers had experienced at least one form of violent and aggressive behaviour in their practice. In general, female healthcare workers experienced violence far more than men, and nurses in particular (66.7%), experienced more violent events than their male counterparts in a South African study. 6

Predictors of aggressive and violent behaviour
There is consensus amongst researchers that there is a positive association between the underlying mental disorders (such as bipolar disorder and schizophrenia) and violent behaviour. According to the NICE Expert Committee Report, the life-time prevalence of violence in non-psychiatric population of 7.3% was lower than those with underlying mental illness of 16.1%. However, individuals with substance use disorders were more likely to be violent (35%). The prevalence of violent behaviour increased to 43.6% in individuals with substance use disorder and comorbid mental disorders. 2 The tendency towards violent behaviour increased in the presence of substance misuse, irrespective of the presence of underlying mental disorders.
Whilst the attending clinicians (doctors and nurses) should take necessary precautions in approaching patients with underlying mental disorders in the ECs, a more cautious approach to individuals with a history of substance misuse, whether with comorbid mental disorders or not, is recommended. 8 The attending doctor must obtain a comprehensive history, which includes the psychiatric history either from the patient or collateral sources with a view of uncovering the underlying condition(s). Medical history of violent and aggressive behaviour could give insight into future recurrences. The history should explore the pre-morbid state, ongoing medical conditions, personality disorders, mental conditions, substance use and psychological issues of the patient. Table 1 9,10 provides a comprehensive but non-exhaustive list of conditions that are associated with aggressive and violent behaviour in patients. The attending doctor should not always assume that the aggression is because of the mental illness. As such, a thorough history and examination are recommended for each episode of aggressive and violent behaviour at presentation in the ECs.
In addition, a mental state examination (Table 2 11 ) and the general physical examination should be attempted in the emergency unit before sedating the patient. This often proves difficult to accomplish in the context of a violent and aggressive patient; however, the attending clinician should  document his or her attempt at accomplishing this task including the findings. The goal of the clinician is to uncover the underlying aetiology of the person's aggressive and violent behaviour. The attending clinician should also be aware that the clinical assessment of patients with violent and aggressive behaviour is a dynamic process. As such, periodic evaluation of the patient is recommended.

Investigations required to exclude a general medical condition
Rational use of laboratory investigations has become critical in the light of the limited budget and increasing health expenditures. However, the evidence-based decision on the initial work-up of patients with aggressive and violent behaviour should target common conditions that are prevalent in the population (

Management approach for violent and aggressive patients Non-pharmacological
In the South African context, the essential drug list of the National Department of Health provides a guide for managing behaviourally disturbed patients. As such, clinicians working in the EC should be well equipped to manage patients with aggressive and violent behaviours. However, few challenges in the South African context range from emergency room architectural design challenges, high patient-to-nurse ratios, lack of security personnel, high prevalence of substance abuse, high crime rates in the general population, and limited medication options. 13 The primary goal of any intervention towards agitated behaviour is to ensure safety, facilitate assessment of underlying problems and prevent further escalation, through achieving calmness and collaboration. 10,14 Minimisation of risk to self, others and environment should be the primary aim of all interventions. Common non-pharmacological interventions can be grouped into educational, interpersonal, environmental, and physical responses targeted at the preevent, event, or post-event phase (Haddon matrix). Manual restraint may be necessary to administer treatment to the patient. Mechanical restraints should be used only when absolutely necessary to protect the patient and others in an acute setting for as short a period as possible. 10  Involuntary and assisted admission of a mental health care user (patient) (MHCU) for treatment, care, and rehabilitation is both a medical and a legal process. 12 Any admission should be done according to the Mental Health Care Act, 17 of 2002. 15 The indications for assisted or involuntary admission are 12 as follows: • There must be a presence of a mental illness.
• There must be a high likelihood to cause serious harm to self or others (suicidal/homicidal) or to cause harm to their financial interests or reputation. • The person cannot make an informed decision on the need for treatment and rehabilitation. • The person is not unwilling to receive treatment (does not object -passive consent) in case of the assisted user or the person outrightly objects to receive treatment and rehabilitation in case of involuntary user.

Pharmacological management
Pharmacological management can be conceptualised in the acute setting (immediate sedation) and for the long-term prevention in persistently violent and aggressive patients.

Acute setting
The aim is to reach calmness within a maximum period of 2 h whilst avoiding adverse effects. Olanzapine was the most frequently studied drug in a systematic review by Bak et al. 14 Changes at 2 h showed the strongest effect for haloperidol plus promethazine, risperidone, olanzapine, droperidol and aripiprazole. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam. 16 Oral Benzodiazepines; Lorazepam, oral, 0.5 mg -2.0 mg, or Clonazepam, oral 0.5 mg -2.0 mg, or Diazepam, oral, 5 mg -10 mg or Midazolam, buccal, 7.5 mg -15.0 mg, should be prioritised first, according to the Essential Drug List. 10 Oral administration of treatment is the safest route.
For patients who did not respond to a repeated oral sedation, refuse oral sedation, or place themselves and others at significant risk, intramuscular sedation for rapid tranquilisation is recommended. Rapid tranquilisation with a short-acting benzodiazepines, for example: Lorazepam 0. Patients with underlying psychosis can be given haloperidol and promethazine as first-line treatment rather than benzodiazepines. In patients suspected of alcohol intoxication, thiamine, oral 300 mg, should be added and continued daily for 14 days. 10 Always monitor the vital signs of a sedated patient. Rapid tranquillisation may cause cardiovascular collapse, respiratory depression, neuroleptic malignant syndrome and acute dystonic reactions. Sedation of children with psychotropic agents should only be considered in extreme cases and only after consultation with a psychiatrist. The current trend is for use of newer, yet equally potent agents, with better side effect profiles over traditional agents like haloperidol, clotiapine (etomine) and zuclopenthixol acetate injection (clopixol acuphase); yet most of the newer agents are not all available in South Africa, especially in the public sector.
Haloperidol intramuscular injection often combined with Lorazepam 2 mg -4 mg is still the mainstay of care in the ECs in South Africa. Oversedation, dystonic reactions (laryngospasm, oculogyric crisis and torticollis) and akathisia (inner feeling of restlessness) are common unwanted effects with haloperidol. Very little published data supports the use of zuclopenthixol acetate injection (clopixol acuphase), and it should not be used as a first line for rapid tranquilisation. Avoid the use of zuclopenthixol acetate on anti-psychotic naïve patients, patients with known cardiac conditions and in patients with a history of extrapyramidal side effects. Its onset of action is often delayed and its effects may last for 2-3 days. Therefore, zuclopenthixol acetate (clopixol acuphase) should only be used after an acutely psychotic patient has required repeated injections of short-acting antipsychotics such as haloperidol or olanzapine and/or sedative drugs such as lorazepam, and these have not been effective. 17 Dose ranges between 50 mg and 150 mg, repeated, if necessary, after 2 days or 3 days. Figure 1 12 summarises the approach to the management of an aggressive and violent patient in the EC, which can be easily implemented at all the district hospitals in the country.
In a review of the literature by Carpenter et al., 16 there was no significant evidence to support the use of clotiapine (etomine) rather than other 'standard' or 'non-standard' treatments for the management of acute psychotic illness. This further points to the fact that good randomised controlled trials (RCTs) are needed.

Persistent violence and aggression in chronic psychiatric patients
Persistent violence and aggression are very common amongst chronic psychiatric patients and state patients, substance abusers, major neurocognitive disorders and patients with intellectual disability. 18 These patients are mostly encountered in psychiatric inpatients and forensic psychiatry settings. The move towards de-institutionalisation, with its advantages and disadvantages, has resulted in individuals with serious mental illness living in the community and having frequent visits to local ECs. State patients (a person so classified by a court directive in terms of section 77(6)(a)(i) or 78(6)(i)(aa) of the Criminal Procedure Act and detained in a psychiatric hospital or a prison pending the decision of a judge in chambers in terms of section 47 of the MHCA (2002) are often given leave of absence, conditional or unconditional discharges. 15 During these periods, they are often required to access treatment, care and rehabilitation at their local hospitals. Studies have also shown that when these individuals are treated, the incidence of violent behaviour decreases significantly.
Three categories could be used to define these aggressive acts: psychotic, impulsive, and predatory (also called organised or instrumental) ( Table 5 18 ). Impulsive violence is the most common form seen amongst chronic psychiatric inpatients despite the high prevalence of psychosis.
Evidence is most robust for psychotic and impulsive aggression. Organised or instrumental violence is generally not amenable to pharmacotherapy and requires behavioural techniques and custodial management. Psychotic violence and aggression are the direct products of poorly controlled positive symptoms of psychosis; therefore, their treatment is consistent with known algorithms for managing inadequate responders. 2 Clozapine should be considered after non-response to at least two adequate trials of antipsychotics and clinicians should familiarise themselves with initiation of clozapine therapy, management of patients on clozapine and recognition of clozapine side effects. Patients with a diagnosis of schizoaffective disorder, bipolar type, may not respond sufficiently to anti-psychotic monotherapy, and mood stabilisation is often necessary to control partially remitted mania or hypomania that continues to drive psychotic symptoms. 19 Clozapine also emerges as the preferred agent for impulsive violence and aggression, and its anti-aggressive property in these individuals is independent of its impact on psychotic symptoms. Adjunctive options include sodium valproate, centrally acting beta-adrenergic antagonists, lithium and selective serotonin re-uptake inhibitors (SSRIs) antidepressants.  Ensure safety of yourself, staff, the paƟent and other paƟents Ensure security personnel are available and ready. Screen for weapons and disarm the paƟent. Assess the paƟent in a calming room with help readily available. Ensure that neither you nor the paƟent feels threatened during the assessment.

Containment
AƩempt to contain the situaƟon by remaining calm and non-threatening in your approach to the paƟent. Offer help as needed and be ready to restrain the paƟent.

Physical restraint
This should be limited to a short duraƟon whilst preparing for chemical restraints.
A 5-point immobilisaƟon -one person per limb and one for the head. Do not use unnecessary force. Protect the airway and apply monitors. PaƟent must be in supine posiƟon. Never leave the paƟent unaƩended.

Sub-types Characteristics Percentage
Psychotic Behaviour is motivated by positive symptoms of psychosis (hallucinations, delusions)

Predatory/ Organised
Planned behaviour with clear goals in mind, for example; intimidation, retribution, monetary or material gain.
Behaviour not obviously a response to threat or provocation.
Often accompanied by limited autonomic arousal.

29
Impulsive Behaviour is precipitated by provocation, threat and stress. Often associated with fear, anger and frustration. High levels of autonomic arousal. Based on the small number of RCTs, only the centrally acting beta-blockers (Propranolol) had strong evidence for efficacy for non-psychotic violent and aggressive patients with traumatic brain injury. 20 Carbamazepine and sodium valproate seem effective for agitation and aggression in traumatic brain injury and are recommended as first-line treatment with sodium valproate having a lesser side effect profile. Amongst the pharmacologic options for persistent aggression in patients with major neurocognitive disorder, the strongest evidence points to the benefits of acetylcholine esterase inhibitors (AChEls) for neuropsychiatric symptoms of mild-to-moderate Alzheimer's disease. Mematine (an N-methyl-D-aspartate [NMDA]) receptor antagonist used in the management of Alzheimer's disease) has shown efficacy for both aggression and loss of appetite in patients with Alzheimer's disease. It is effective both as monotherapy and when combined with AChEIs. Selective serotonin re-uptake inhibitors have also shown some efficacy. Anti-psychotics are associated with the risk of mortality and morbidity in these patients and should be used with caution. First-generation antipsychotics should be avoided at all costs, if possible.
In conclusion, clinicians working at the district hospitals must be aware that patients with aggressive and violent behaviour often present at the ECs. They must receive training in deescalation protocol and the management approach for patients with aggressive and violent behaviour. Oral treatment should be prioritised when feasible. However, mechanical restraints can be applied minimally with a view of achieving sedation in some patients through parenteral route.