Wong Ambrose H, Ruppel Halley, Crispino Lauren J, Rosenberg Alana, Iennaco Joanne D, Vaca Federico E
Jt Comm J Qual Patient Saf. 2018 May;44(5):279-292. doi: 10.1016/j.jcjq.2017.11.011. Epub 2018 Apr 23.
The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation.
A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management.
Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes.
Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.
前往急诊科（ED）的躁动患者人数不断增加，对医护人员和患者构成了越来越大的安全威胁。由于缺乏一个结构化框架来审视急诊科躁动患者的护理，基于证据的策略发展受到限制。在本研究中，采用了患者安全文献中的系统方法来推导一个全面的理论框架，以应对急诊科患者的躁动。
采用混合方法，研究对象为一个区域医疗网络的学术机构和社区机构的急诊科工作人员。参与者包括住院医师和主治医师、医师助理/执业护士、护士、技术人员和安保人员。在模拟一次与躁动患者的接触以激发参与者的讨论后，开展了单专业和跨专业焦点小组讨论，随后采用扎根理论方法进行结构化主题分析。定量数据包括对暴力暴露情况以及对患者攻击行为和管理态度的调查。
57名参与者的数据达到饱和。技术人员、护士和安保人员的暴力暴露率更高。由于四个主要相互关联的因素，出现了相互冲突的优先事项和管理挑战：患者动机被认为复杂；在职业责任和个人安全之间存在患者护理悖论；通过尊重和信任缓解的跨专业动态不和谐；以及阻碍护理提供和长期结果的后勤挑战。
采用系统方法，确定了急诊科躁动患者护理的五个相互关联的层面：患者、工作人员、团队、急诊科微观系统和医疗宏观系统。这些护理维度被综合起来形成了一个基于患者安全的新颖框架，可有助于指导未来的研究、实践和政策制定。
