Key takeaways:
• Hospitals are deploying different strategies for prevention and de-escalation.
• A consistent response helps defuse patients sooner and allow staff to experience less psychological harm.
• It’s important that all staff know their role in preventing, de-escalating or containing problematic behavior.
THE NUMBER OF VIOLENT incidents in hospitals has been on the rise, exacerbated by the pandemic. In a 2025 report, the American Hospital Association estimated that the annual cost of violence to U.S. hospitals tops $18 billion. That same report acknowledged that it couldn’t estimate the impact of violence on staff recruitment and retention, nor the psychological costs for health care workers.
In 2025, the Journal of Hospital Medicine featured innovations being used in three different academic centers around the country, each designed to prevent hospital violence and to keep staff safe.
The three innovations each highlighted a different facet of how to tackle potential violence in hospitals: prevention, therapeutic interventions and even, as a last resort, discharging patients who won’t modify their behavior. But all three underscored the need for comprehensive, streamlined processes so clinicians and staff know how to de-escalate situations, and who to call when they can’t.
Prevention and de-escalation
Hospital of the University of Pennsylvania
As is the case at most hospitals, clinicians and staff at Philadelphia’s Hospital of the University of Pennsylvania (HUP) had protocols in place before the pandemic to deal with disruptive patients or family members. But those weren’t well-coordinated or as comprehensive as they needed to be.
“There was no streamlined path for what to do, who to call, who would respond and what would happen.”
Christina Vo, MSN
Hospital of the University of Pennsylvania
“There was no streamlined path for what to do, who to call, who would respond and what would happen,” says Christina Vo, MSN, a nurse practitioner who is one of HUP’s interdisciplinary patient safety officers. Ms. Vo is also lead author of her and her team’s write-up in the JHM.
Previous efforts also weren’t as multidisciplinary as they needed to be, says hospitalist Emmanuel King, MD. While de-escalation training was offered to nurses, providers were often left out of that loop.
As a result, “we used to collectively struggle with how to handle these situations when they came up,” says Dr. King. “Should we call a physician or a nurse practitioner to the bedside to talk to the patient? Or did we need to call security? That all led to an inconsistent response, which would escalate patients even more.”
In 2023, both Ms. Vo and Dr. King as well as Karen Brooks, DNP, RN, became part of a committee to address workplace violence across HUP, with Ms. Vo as co-leader. That team came up with a three-pronged approach, with different portions of that pathway being piloted at HUP at different times.
Anticipatory guidance
The first component is what Ms. Vo and her colleagues call anticipatory guidance. A key part of this preventive stage has been including a handout in patients’ admission packets that references emotions—utilizing pictures of facial expressions, similar to the pain scale—that range from anxiety to loneliness to feeling overwhelmed.
“We find that depicting emotions about being hospitalized helps meet patients where they are,” says Dr. Brooks. “We’re also flipping the script.” For health care workers, she explains, the hospital is a very familiar place to be. But for patients, “these can be the worst days of their lives. The handout acknowledges that this situation is not normal for them.”
“We find that depicting emotions about being hospitalized helps meet patients where they are.”
Karen Brooks, DNP, RN
Hospital of the University of Pennsylvania
The admission packet also offers patients stress management resources they can use while hospitalized, including coloring books, puzzles and reading material as well as pastoral care and therapy dogs. According to the JHM write-up, a two-month pilot of anticipatory guidance on four general medicine units reduced reported incidents of violent and disruptive behavior.
Just as importantly, the staff on those units noted the value of having patients acknowledge how stressful it is being hospitalized. Staff also felt the handouts and stress management resources led to more meaningful conversations with patients and more opportunities for early de-escalation.
De-escalation and a behavioral response team
The second tier of Penn’s violence prevention pathway focuses on de-escalation. That entails training staff in techniques to defuse potentially violent or disruptive behavior. According to Ms. Vo, the center has pulled in techniques based on CDC and HRO (High Reliability Organization) principles.
Staff can also access instruction from the Crisis Prevention Institute, a training organization, in two separate ways: through an online component or in a four-hour in-person course. While taking the training is elective, the academic center is considering making training a requirement for new hires.
Also part of de-escalation: distributing tip sheets that spell out the role of the provider, the nurses, the charge nurse in tough situations that arise.
“We have a lot of churn with provider rotations every two weeks,” Dr. Brooks notes. “If something comes up and someone isn’t sure what to do, the tip sheet is available to walk them through the steps.”
“Now, everyone knows to treat violent or disruptive behavior just like a medical emergency, except you call a different set of resources to the bedside.”
Emmanuel King, MD
Hospital of the University of Pennsylvania
When de-escalation doesn’t succeed, the third component of the response pathway—calling the behavioral response team, which consists of security and the patient’s covering provider—kicks in.
Having that team in place preceded Ms. Vo and the response committee. “But there were gaps in response times for when security or medications or restraints would arrive,” she says. “We worked within the committee to minimize those time gaps.”
Dr. Brooks also highlights one big advancement with the streamlined behavioral response team: eliminating barriers to pulling needed medications.
“Certain medications now are on override in our Omnicells,” she points out, referring to the automated medication management systems used on the wards. Typically, doctors must place a physical order—for Ativan, for instance—in the medical record, which a pharmacist has to then verify.
Now, in time-sensitive situations when patients are acting out, “nurses can pull the medication from the Omnicell and do the documentation on the back end along with a provider order.” That change came through collaboration with the pharmacy and hospital leadership.
A system-wide roll-out
Ms. Vo and her colleagues piloted the three-tier pathway on 10 HUP units.
“We saw a reduction in workplace violence events in the advanced medical units,” she says. Committee members did not see a similar decrease in the neuroscience units where the pilot took place. They later realized that was due to many more reports of problematic events being filed, once the committee highlighted the importance of reporting.
She and the violence response team are now working with psychiatry and medicine residents to build out the pathway. They want to craft medication guidelines for disruptive episodes among patients having acute psychosis or behavioral issues related to dementia or delirium.
Ms. Vo and her colleagues are also tasked with rolling out the comprehensive pathway from 10 units in HUP to the entire medical center and to other Penn Medicine facilities.
“That’s very daunting,” she admits. “There’s a lot of interest in looking at how our pathway could be generalized across all the locations in our health system.”
Still, hospitalist Dr. King points out, embedding a pathway so everyone knows how and when to respond “is a big step forward. Now, everyone knows to treat violent or disruptive behavior just like a medical emergency, except you call a different set of resources to the bedside.”
Tailored care for vulnerable people
COOPER UNIVERSITY HEALTH CARE
Now chief physician executive, Eric Kupersmith, MD, first started working at Cooper University Health Care in Camden, N.J., an academic tertiary care, level 1 trauma center, as a hospitalist in 1998. Over the years, Dr. Kupersmith found that he was one of a handful of clinicians called to intervene with difficult patients.
When dealing with those patients, Dr. Kupersmith says he tried to figure out how to prevent them from becoming disruptive or abusive in the first place. Over the years, “I found an increasing gap developing between providing humanistic care and clinicians’ self-preservation.”
“We wanted to help staff figure out how to talk to a specific patient when they start to escalate.”
Puneet Sahota, MD, PhD
Cooper University Health Care
When tough patients went too far, bedside doctors and nurses would say, “We want this patient out!” While he understood that reaction, he’d respond by asking about what had triggered the patient to elicit the disruptive behavior. “That often earned me a, ‘Are you kidding me?!; from distressed clinicians,” he says.
“I wanted to figure out how to cut off the risk of violence or abuse before it begins by basically offering tailored care to patients who can’t effectively represent their needs,” says Dr. Kupersmith. The push toward that tailored care finally came in October 2023, when staff members at Cooper took a safety survey. Their No. 1 concern was workplace violence.
Before then, Cooper offered employees universal violence prevention training, and it had a well-established workplace violence prevention committee. It also had an interdisciplinary behavioral rapid response team protocol, which included a pre-packaged medication kit and Omnicell override for as-needed medications as well.
“Many hospitals have these behavioral rapid response teams and they’re considered best practice,” says Puneet Sahota, MD, PhD, division head of consultation-liaison & emergency psychiatry at Cooper. “But they’re reactive.” She and her colleagues began working with Dr. Kupersmith to formulate a more proactive approach.
Psychology resources
Fortunately, points out Dr. Sahota, Cooper has a very deep bench of psychiatry and psychology resources, including a psychology consult service that’s distinct from psychiatry.
“That is very rare among hospitals,” she notes. Around the same time that the safety survey results came out, what Dr. Sahota calls “parallel streams”—independent efforts within different parts of the organization—cropped up as partial responses to staff safety concerns.
“We’ve literally created a concierge service for vulnerable people.”
Eric Kupersmith, MD
Cooper University Health Care
For one, campus security strengthened infrastructure with better lighting. The academic center also invested in giving all staff a personal panic badge to wear at all times. And psychology leadership suggested scripted care plans for individual patients to help prevent ongoing disruptiveness and potentially threatening behavior.
That’s when Drs. Kupersmith and Sahota began connecting those various activities to address at-risk patients before disruption begins.
“We wanted to help staff figure out how to talk to a specific patient when they start to escalate,” says Dr. Sahota. Those strands came together in a multidisciplinary team dubbed therapeutic violence mitigation (TVM, which formally debuted in February 2024 with Dr. Sahota as medical director of TVM & team safety.
The charge of TVM was two-fold: to develop a systems approach to identify at-risk patients before issues arose and to support care teams with tailored care plans for individual patients.
The TVM team is made up of three clinicians: a psychiatrist (Dr. Sahota), a psychologist and a hospitalist. The team worked with informatics to craft a text alert that’s sent to team members when a patient with a prior history of violence or disruption comes to the ED.
TVM members then reach out to the care team to remind them to look through that patient’s individual behavioral care plan; those plans are drafted by TVM members and stored in the EHR. Each plan outlines a patient’s clinical background and mental health history as well as specific triggers, tips for how that patient should be approached, and details about how they respond to different de-escalation or calming techniques.
A change in culture
In their Journal of Hospital Medicine write-up, Dr. Sahota and her colleagues described the TVM pilot program, which centered on four patients. In the year leading up to the pilot, the four patients collectively had been responsible for 67 escalation events including behavioral rapid responses called and incident reports filed.
In the six months after TVM was initiated, only two violent events were recorded among the four patients. Those results convinced administration to expand the program to include other patients at risk. More than a year later, says Dr. Sahota, the TVM program now includes close to 150 patients, all of whom have individual behavioral care plans. To get the program off the ground, each of the three TVM clinicians received about 10% of their clinical time to dedicate to the program.
As for how much more comfortable staff feels now caring for at-risk patients, Dr. Sahota notes that the center’s culture has changed.
“TVM team members still get alerts when a patient presents, and one of us still reaches out to the care team,” she says. “Usually, that team has already looked through the care plan and their response is, ‘Yeah, yeah, we got it.’ ” Because nurses and providers are now engaging with patients much more quickly, she adds, patients “are modifying their behavior.”
Strategic use of standard precautions
The scripts used in patients’ behavioral care plans are based on the principles of Project BETA (Best practices in the Evaluation and Treatment of Agitation), a framework for verbal de-escalation.
Dr. Sahota also credits the early and strategic use of standard hospital precautions for suicidal and homicidal ideation. Those precautions include one-on-one observation, securing personal belongings and cell phones, and having to use a “safe tray” with finger food and no silverware.
“There is actually therapeutic value in the timing and deployment of these precautions,” she notes. When interacting with someone who’s threatened to harm a nurse, for instance, “I say, ‘We take safety very seriously, and we’re going to follow our hospital’s protocol for making your room a safe environment. This is what that involves.’ ”
Those precautions “paradoxically have a calming effect, not in the moment when patients get upset about having their phone taken away but afterwards, when they have time to reflect,” Dr. Sahota says. She also believes that one-on-one observers help mitigate patients’ behavior.
“They develop a back-and-forth with patients and let them know that they’ll get their phone back if they show that they can remain calm and not threaten to harm themselves or others,” she says. “One-on-one companions are part of the therapeutic team.”
Once patients realize they want their phones back and silverware to eat, “then we can have a therapeutic conversation. That’s when a patient’s insight improves and their behavior changes.”
Another important resource: Nursing leadership began hiring behavioral clinical specialist nurses in 2024.
“We very quickly integrated them into our workflows so we could be an interdisciplinary team,” Dr. Sahota says. The behavioral clinical specialists “go to the bedside every day based on which patients are at highest risk of violence. They coach and support the bedside nurses in how to implement care plans and de-escalate interactions.”
A streamlined workflow
Dr. Sahota and her colleagues are now creating similar care plans for patients with other reasons for behavioral dysregulation including traumatic brain injury, dementia, delirium, intellectual disability and autism.
She is aware that flagging patients as being at risk for violence in the EHR can be stigmatizing. But she notes that the flag in use at Cooper University Hospital is a safety alert, not a violence flag, one linked in the EHR to that patient’s care coordination plan.
“The alert immediately tells staff to read the behavioral care plan and communication script, so the flag is therapeutic, not stigmatizing,” she notes. “That’s really important.”
And while Dr. Sahota notes that few institutions have the inpatient psychological resources as her health system, she believes many hospitals could implement a scaled-down version of therapeutic violence mitigation. Most hospitals already have a psychiatry consult service and security.
“What was key was streamlining those into a systematic workflow,” says Dr. Sahota. “I believe all hospitals have the potential to do that even if they don’t have all these formal resources.”
As for chief physician executive Dr. Kupersmith, he’s gratified to finally see patients get the time and attention they need. “We’ve literally created a concierge service for vulnerable people,” he says, “to help them better manage in our health system.” At the same time, “our nurses and physicians experience less physical and psychological harm while delivering compassionate care.”
Discharging patients as a last resort
Oregon Health and Science University
What about those very rare cases of disruptive patients when preventive techniques and de-escalation still don’t change patient behavior?
That was the dilemma facing clinicians at Oregon Health and Science University (OHSU) in Portland, Ore., who—like providers elsewhere—saw the number of violent and abusive incidents rise significantly during the pandemic. That increase led them to re-examine some underlying assumptions in health care.
“We can all approach these situations with less drama and more process.”
Kellie Littlefield, DO
Oregon Health and Science University
They realized, as hospitalist Kellie Littlefield, DO, points out, that personnel in other industries—think police officers and airline crews—”are empowered by legal and institutional policies to detain or eject individuals for violent or disruptive behavior toward them.”
But hospitals have historically lacked such safeguards. “Health care’s unique culture—shaped by ‘do no harm’ and maybe a belief that patient-inflicted violence is inevitable or unintentional—has fostered underreporting and an unconscious assumption that patients cannot be held accountable,” notes Dr. Littlefield, who works with OHSU’s workplace violence committee. “We want to protect our patients. But we also need to protect our staff and the healing environment.”
For years, the hospital had deployed behavioral response codes as well as trauma-informed care education and staff de-escalation training.
It also had a longstanding administrative discharge policy whereby adult patients who displayed persistently unsafe behavior would, as a last resort, be discharged from the hospital before they were medically ready. But using that policy was challenging, Dr. Littlefield explains. Part of the reason why was because the protocol was unclear about who would make that discharge decision and how the decision would be implemented.
As a result of not having a clear-cut and reliable process, Dr. Littlefield says that care teams “often experienced denial, minimization or learned helplessness, which actually act together to perpetuate violence.”
Clear-cut escalation pathways
In 2021, the rising number of incidents led OHSU to revisit its administrative discharge policy, charging committee members to make it workable. To do so, team members called for several new multidisciplinary roles, robust documentation and clear-cut care escalation pathways.
As detailed in the JHM write-up that Dr. Littlefield was lead author of, in the event of unsafe or disruptive behavior, the protocol holds that nurses first contact the patient’s primary team and document their own observations and assessments. Primary team members consider underlying etiologies for behavioral issues such as delirium, uncontrolled pain or anxiety, and the patient’s mental stability and capacity.
If the patient’s behavior persists despite therapeutic interventions, the bedside care team next reports that behavior to the unit nursing director or to the administrator on duty during weekends and evenings; the bedside team can also call in the physician on duty to help mediate. Both the administrator and physician on duty have hospital leadership roles and expertise in resolving system-level issues.
“If two heads are better than one, then three are better than two,” says Dr. Littlefield about adding the administrator on duty and/or physician on duty to the decision-making mix. “Because an administrative discharge is such a high-stakes decision, we wanted to pull in a leader-representative who can help support the care team, mediate or even offer a different perspective.”
Adding leader-representatives to the mix also shows a clear escalation of concerns, which is important for staff. “That makes it clear to the bedside team that we are there to support and protect them.”
Who makes the final decision?
If unsafe behavior persists, the decision to actually implement an administrative discharge is now made by the hospital’s director of nursing—an important change since the policy’s first iteration.
“The administrative discharge decision used to be planted in the physician realm, which made many of us uncomfortable,” says Dr. Littlefield. “You’re trying to maintain a caring therapeutic relationship with patients and create a medical plan, not focus a visit on negotiating hospital rules.” Another process innovation: having the nursing director give the patient a final warning before they’re discharged, making it clear that their behavior is about to lead to them having to leave the hospital.
“Many times,” she notes, “the final warning has helped us not proceed to administrative discharge. We want to continue to provide care safely, and that piece really helped us.”
In the rare event when the nursing director decides an administrative discharge is necessary, the patient’s primary team arranges for “next best” outpatient support and prescriptions.
The protocol also comes with clear exclusion guidelines. Patients are exempt from a possible administrative discharge if they are psychiatrically or medically vulnerable (including those on a medical or psychiatric hold) as well as those who are under conservatorship or guardianship.
Rare events
In their JHM write-up, Dr. Littlefield and her colleagues note that over the course of 2023, only five administrative discharges took place. One of those five patients, according to the write-up, has been lost to follow-up. But the other four have since been treated at OHSU as well as at other local facilities without any major behavioral concerns.
The team did seek the opinion of the hospital’s legal counsel about administrative discharge in case a patient brought a malpractice claim. The upshot, as Dr. Littlefield and her colleagues write in their article: “Once behavioral expectations are put in place and capacity confirmed, the patient is making the determination to terminate care via refusal to curtail violent behavior.”
Dr. Littlefield says she is not aware of any legal cases pertaining to any administrative discharges. As for how often the policy was enacted in 2024 and 2025, she notes that such discharges remain just as infrequent as in 2023.
“Part of that is we are all now much more facile at approaching these cases and more comfortable because we have clear and defined roles,” she says. “We can all approach these situations with less drama and more process.”
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
