Author: Ajai Raj
It’s just another typical day at an ambulatory surgery center (ASC), until a situation with an unruly patient upends the order. When this happened at an ASC in Colorado, without the larger security department that comes with a full hospital, team members had to make decisions on the fly.
While staff minimized the situation in question quickly, the event showed the need for a protocol to manage disruptive patients and ensure the safety of patients and staff in potentially violent situations. In addition, it highlights the necessity for other centers to adopt similar procedures before their own staff end up in a similar situation, said the Colorado team.
Presenting the case at the annual meeting of the Society for Ambulatory Anesthesia (abstract 1813), researchers from the University of Colorado Anschutz Medical Campus described the incident, in which a patient scheduled for a colonoscopy became verbally abusive and threatening toward the staff. Upon arriving at the ASC, the authors wrote, the patient had a list of demands: first, that she hear nothing regarding her IV tube placement; second, that the IV be placed preprocedurally; and finally, that the IV be placed only in one specific location on her forearm.
At that point, the patient escalated her aggression, calling the CRNA a “whore” and threatening all staff present—a gastroenterologist and a nurse, in addition to the CRNA and anesthesiologist—that she would “have their [asses].”
Even though the authors were able to calm the patient by explaining they were seeking to avoid a painful IV placement, during the subsequent attempt at ultrasound-guided IV placement, the patient told a member of the anesthesia team, “I’m going to kill you.”
A Wake-up Call
Fortunately, although the patient remained antagonistic through the remainder of her roughly two-hour visit—threatening to get staff members fired and demanding apologies—the situation did not escalate beyond verbal abuse and threats, and the colonoscopy was successfully performed.
“I think in the course of practice, we all encounter varying degrees of challenging patients—and I want to say ‘challenging’ as opposed to ‘difficult,’ because the patient is often stressed out and not in their comfort zone, and it’s not unreasonable that they might not always act like themselves under such circumstances—but I would say that in this case, the patient exhibited an extreme response to a stressful situation,” said Ramakrishna Gumidyala, MD, an assistant professor of anesthesiology at the University of Colorado School of Medicine, in Aurora, and one of the authors of the study.
Dr. Gumidyala said the incident served as a wake-up call for him and his colleagues, leading them to formulate a policy for addressing and defusing potentially dangerous incidents such as this one as soon as they arise, and before they escalate.
“One major thing we discussed in our staff huddle after this incident was bringing up potential safety concerns earlier rather than later—even if the risk of violence is low, urging people to communicate with each other if they should be on their guard,” he said. “Another important step is making people aware of the safety protocols in case we need to call for outside help, given that we have no in-house security, so we’ve posted signs describing this disruptive behavior protocol throughout the surgery center so it’s accessible and visible at all times.”
As an example of this proactive approach, Dr. Gumidyala described a recent situation in which a patient was known to have an abusive spouse who might have shown up at the center. “It didn’t sound like that patient’s partner was going to be coming, but we sent out an email to staff the day before to notify them of the potential problem.”
Ann Shimek, RN, MSN, the senior vice president of clinical operations for United Surgical Partners International, an ASC management company based in Dallas that oversees approximately 260 ASCs, praised the policy as outlined in the study, noting that her company has similar policies in place at its facilities.
“Situations like this are rare, but they do happen,” said Ms. Shimek, who is also a member of the board of directors of the Ambulatory Surgery Center Association. “It’s important to have everyone on staff be aware when there’s a potential incident, and to know the protocol for what to do in a dangerous situation. Usually we try to get the physician involved, and the medical director if they’re present, to de-escalate the situation.”
Dr. Gumidyala likewise stressed the importance of de-escalation. “The earlier you can flag potential concerns and make everyone on staff aware, the more likely you are to contain a situation that doesn’t need to escalate.”