As of September 1, 2017, this administrative policy applies to the operations and staff of legacy UWHC. Effective
July 1, 2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of Wisconsin
Hospitals and Clinics Authority (UWHCA). All administrative policies are being transitioned to apply UWHCA-wide,
but until future revision to this policy #10.16, it applies only to the operations and staff of legacy UWHC.
10.16 Aggressive or Disruptive Patient Behavior in the Emergency Department
UWHC Administrative Policy
September 1, 2017
Mental Health (Hospital Administrative)
To provide guidelines for management of aggressive or other disruptive patients admitted to the Emergency
Department, for example combative behavior due to medication, alcohol, anxiety or hypoxia.
Patients entering the Emergency Department (ED) who exhibit disruptive behavior will be treated in a manner so
as to protect them and others while minimizing disruption to the ED.
If the Police, Fire Rescue, or an Ambulance service transports the patient, they will be asked to remain with the
patient until additional support is available or until the Emergency Department staff does not require their
assistance. Every attempt will be made to minimize the waiting time of Police and/or ambulance services.
A. Police and/or ambulance personnel should assist staff in controlling the patient until assistance is no
longer needed or Security arrives.
B. The patient will be registered in the ED and a medical evaluation completed.
C. A collaborative decision will be made as to what level of protection control will be required on a continuing
basis. UW Health clinical policy #2.4.2, Restraint and Seclusion should be followed for patients requiring
restraint and seclusion for management of violent or aggressive behavior.
D. For patients requiring inpatient admission, disposition will be determined as follows:
1. General Admission.
a. Routine admission procedures should be followed for patients with no protection support
requirement, e.g., restraint is not required.
b. When protection support is required the Nursing Coordinator will be contacted to
determine the appropriate inpatient unit placement based on the patient's monitoring
needs and staffing requirements. If monitoring includes the need for a personal safety
attendant (PSA), the Nursing Coordinator will work with the Nursing Resource Center to
meet unit staffing needs prior to inpatient admission. This may include staffing support
to the ED during treatment and evaluation. Protection support may also be provided by
Security and/or the University of Wisconsin (UW) Police.
2. Psychiatric Admission
a. Patients requiring inpatient psychiatric care may be admitted to the Inpatient
Psychiatric unit following Hospital Administrative Policy 10.13-Patient Acknowledgement
of Inpatient Psych Admit.
E. Emergency Department Staff Nurse Responsibility
1. Call the Behavioral Response Team for assistance as required. Security officers and inpatient
psychiatry staff will respond.
2. The Security Officer in charge will determine the need for further assistance and will contact UW
Police if needed.
F. Security Responsibility
1. If required, Security will remain with the patient in the ED for as long as reasonably needed
to control the situation.
2. The security officer should remain with the patient until the physician in charge indicates that the
emergency situation is under control.
G. Nursing Coordinator Responsibility
1. Assess continuing care requirements in the ED and coordinate inpatient placement.
2. Communicate placement requirements to Nursing Resource Center to ensure required staffing
support is provided to admitting unit, e.g. need for PSA support.
Senior Management Sponsor: Sr. VP, Patient Care Services and CNO
Authors: Director, Emergency Department
Reviewer(s): Director, Risk Management; Director, Security
Approval Committee: UW Health Clinical Policy Committee
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee