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Policies,Clinical,UW Health Clinical,General Care and Procedures,Behavioral Health

Assault By a Combative Patient (2.4.3)

Assault By a Combative Patient (2.4.3) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Behavioral Health

2.4.3


UW HEALTH CLINICAL POLICY 1
Policy Title: Assault by a Combative Patient
Policy Number: 2.4.3
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 21, 2016

I. PURPOSE

To establish procedures to be follow ed in case of assault by a patient to staff , visitors, or other patients.

II. POLICY ELEMENTS

UW Health has adopted the follow ing procedures for assault of patients, visitors, or staff by a patient.

III. PROCEDURE

A. An effort is made to identify patients w ith a developing behavioral crisis. It is important to recognize that
agitated, aggressive, or assaultive behavior often has factors contributing to the crisis such as an intense
frustration over a situation in w hich the patient has very little control and/or the result of physiological and/or
psychological illness. Early identif ication can potentially lead to successful de-escalation.
B. In case of an assault by a combative patient, the staff should remove everyone at risk from the situation and
call the Behavioral Response Team. The combative patient may be secluded (Inpatient psychiatry only)
and/or restrained as needed. See UWHC policy #7.36, Emergency Response Teams, and UWHC #10.27,
Restraint and Seclusion. The physician should be notif ied of patient’s assaultive behavior and if appropriate
order Aggression Precautions. Inform all other staff on the unit of combative patient’s potential for violence.
C. At least one staff person should attend to the needs of the assaulted individual.
i. If the assaulted individual is another patient, the patient should be examined by either the staff
physician or the on call physician and appropriate medical attention given w ith subsequent
documentation in the medical record. The incident should be reported using the Patient Safety Net.
ii. If the assaulted individual is a staff member, he/she should be examined at Employee Health, w hen
they are open and in the Emergency Department at all other times. The assaulted employee’s
manager should be notif ied during business hours and the Nursing Coordinator and/or Care Team
Leader should be notif ied at other times. The Accident and Illness Report (found on U-Connect)
should be completed by the employee. The incident should also be reported using the Patient
Safety Net.

IV. COORDINATION

Author: Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Chair, Nursing Patient Care Policy and Procedures Committee; General Counsel; Director,
Psychiatric Services
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD



UW HEALTH CLINICAL POLICY 2
Policy Title: Assault by a Combative Patient
Policy Number: 2.4.3

Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHC policy #7.36, Emergency Response Teams
UWHC policy #10.27, Restraint and Seclusion

VII. REVIEW DETAILS

Version: Revision
Next Revision Due: January 21, 2019
Formerly Know n as: Hospital Administrative policy #10.20