title: Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation-Enhanced Interprofessional Curriculum.
abstract: BACKGROUND
  While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design.
  
  
  METHODS
  Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs.
  
  
  RESULTS
  One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training.
  
  
  CONCLUSIONS
  A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.
authors.affiliation: Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.
authors.forename: Ambrose H
authors.initials: AH
authors.lastname: Wong
authors.affiliation: Bellevue Hospital Center, Adult Emergency Services, New York, New York.
authors.forename: Lisa
authors.initials: L
authors.lastname: Wing
authors.affiliation: Bellevue Hospital Center, Hospital Police, New York, New York.
authors.forename: Brenda
authors.initials: B
authors.lastname: Weiss
authors.affiliation: New York University School of Medicine, Department of Emergency Medicine, New York, New York.
authors.forename: Maureen
authors.initials: M
authors.lastname: Gang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D003479:Curriculum; D004502:Education, Medical, Continuing / Q000379:methods*; D004509:Education, Nursing, Continuing / Q000379:methods*; D004630:Emergencies; D004635:Emergency Medicine / Q000193:education; D004636:Emergency Service, Hospital / Q000458:organization & administration; D004637:Emergency Services, Psychiatric / Q000379:methods* / Q000458:organization & administration; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D009518:New York; D010348:Patient Care Team / Q000458:organization & administration*; D061214:Patient Safety; D016495:Police; D024382:Professional Role; D000066908:Simulation Training / Q000379:methods*; D064450:Workplace Violence / Q000517:prevention & control* / Q000523:psychology