Patient violence jumps at state psychiatric hospitals www.privateofficer.com
Austin TX Jan 28 2013
Patient-on-patient violence at Austin State Hospital has soared more than 170 percent over the past five years, one of the most dramatic increases in a system seeing an escalating number of such episodes at all of its inpatient psychiatric facilities.
According to an American-Statesman analysis, incidents of violence at all of the state-run hospitals have increased 22 percent since 2008, rising from 2,700 to 3,300 in fiscal 2012.
Hospital staffers are also being injured by patients. Although the overall number of patient-inflicted injuries has hovered at about 2,000 over the past five years, workers’ compensation claims by hospital staffers have increased 40 percent, rising from 448 in 2008 to 629 in 2012.
The vast majority of incidents at all 10 hospitals, 97 percent, required only first aid or no treatment at all. But records from the Health and Human Services Commission’s Office of Inspector General offer details on the kinds of violence occurring at the hospitals. In November, an Austin State Hospital patient sleeping on the floor was kicked in the head and face by another patient. In August, an Austin State Hospital patient repeatedly hit a doctor with a clothes hamper. In September, a Terrell State Hospital patient punched an employee in the face, pulled her hair, kicked her and scratched her.
The Department of State Health Services, which oversees the hospitals, attributes the rising numbers to the fact that staffers are now reporting incidents more often and that hospitals are taking in sicker patients than in the past. The state couldn’t immediately provide statistics to support those assertions. But the average length of stay at the hospitals has increased from 47 days in 2008 to 58 last year, which is an indicator of the severity of illnesses that patients are experiencing, said department spokeswoman Carrie Williams.
“Local crisis systems are now better able to take care of the less extreme cases,” said Williams. “There are more outpatient opportunities in the community, so the patients that come to us are the most acutely ill with the most serious problems.”
Disability Rights Texas, a federally required protection and advocacy group for Texans with disabilities, says the surging numbers raise questions about whether staffers are adequately trained to respond to such problems; whether there are enough employees to monitor patients; and whether clients are receiving meaningful treatment that helps them control their behavior.
“Too many patients are not appropriately supervised by staff and are also not engaged and have little or nothing to do with their time, despite the fact that adequate staffing and therapeutic engagement are recognized best practices for managing a healthy and safe hospital environment,” said Beth Mitchell with the disability rights group.
Any kind of violence can make it difficult for patients to focus on recovery, said Dr. Jim Van Norman, chief medical officer for Austin Travis County Integral Care, which provides mental health services for low-income and uninsured people.
“Feeling unsafe would make it difficult to restore the person’s ability to function in the community,” he said.
Austin State Hospital, which houses 300 patients at a time, didn’t experience the largest percentage increase in reported violence in the state’s psychiatric system. The 74-bed El Paso Psychiatric Center saw a nearly 300 percent increase in incidents, from 12 to 47 in the past five years.
Neither does Austin have most incidents per year. That distinction goes to Rusk State Hospital, with 335 patients and 1,200 episodes of violence in 2012.
But the Austin facility did see the largest increase in the number of incidents, rising from 244 to 633 incidents during that time period. Austin State Hospital, located at 4110 Guadalupe St., now accounts for 20 percent of all such episodes in the system, up from 9 percent in 2008.
Williams says the department is researching why the Austin increase in violent incidents far surpasses that of other hospitals, despite other positive indicators. Its staff vacancy rate, 5 percent, was below the state average of 8 percent in 2012. Its 1.9 percent employee turnover rate was also lower than the 2.4 percent average statewide.
Texas’ state-run psychiatric hospitals are inpatient facilities for people with serious mental illnesses, such as bipolar disorder and schizophrenia. Patients receive medication, social work services and other treatment.
Experts say that people with such illnesses are no more violent than others in the general population. But violence isn’t uncommon in psychiatric hospitals, where patients arrive in unstable mental conditions and have impulse control problems, said Dr. Carl Bell, a professor with University of Illinois’ Department of Psychiatry and School of Public Health. Bell compares such patients to a car with “all gasoline and no steering wheel or brakes.”
Patient violence in psychiatric hospitals is usually perpetrated by a small number of patients, according to a 2004 study of a North Carolina psychiatric hospital. There, researchers determined that 1.4 percent of patients accounted for 56 percent of all violent episodes recorded in the study. Of these people, 63 percent had an intellectual disability, a traumatic head injury, a personality disorder or other neurological problems.
Most state hospitals aren’t equipped to deal with “manifestly dangerous patients” who remain a threat to those around them, Williams said. State Health Services adopted a policy last year that requires hospitals to transfer overtly dangerous people as quickly as possible to the North Texas State Hospital in Vernon, a maximum security facility that specializes in patients accused of crimes.
Treating patients like prisoners is part of the problem, Mitchell said. Hospitals have become more punitive than therapeutic, which creates an atmosphere of fear and frustration, she said. The longer stays also contribute to the problem.
“They are bored, understimulated and hopeless due to the discouraging prospects for release,” she said.
Williams disputes the assertion that patients aren’t engaged in meaningful activities.
“We work really hard to provide all kinds of treatment and recreational programs to help get patients well and get them moving,” she said. “We educate patients about their medications and involve them in their treatment planning.”
Many violent incidents can be avoided with proper training, Bell said. Staffers need to talk to patients from the start about expectations, potential consequences, goals for treatment and patients’ hopes for the future.
“I tell them, ‘Hitting me isn’t going to help you reach your goals. If you can show me in some way that hitting me helps you reach your goals, I’ll put it in your treatment plan,’” said Bell.
Meanwhile, staffers must recognize the signs of patients on the verge of immediate violence, such as yelling or aggressive body language, said Bell. That behavior signals the need for workers to step in with basic conflict resolution skills — listening, empathy, patience — instead of avoiding the patient entirely.
“You don’t go change the toilet paper or go on break or run away,” Bell said.
Williams says the hospitals educate their staff on those very issues, requiring incoming employees to take 20 hours of training to learn how to build trust with patients, anticipate violence, avoid restraining patients and keep themselves safe during violent incidents.
Once on the job, staffers must take an 8-hour refresher course annually, Williams said. They do everything they can to avoid physical interventions, which is safer for both employees and patients, she said.
“Employees sometimes have to control and calm someone who is physically acting out,” Williams said. “It’s a very difficult situation, but our staff is well trained to de-escalate and soothe aggressive patients who are having a rough time. They do it every day, and do it very well, but it’s sometimes not without incident.”