Otolaryngologists Apply Safety Strategies When Treating Threatening Patients

Vinciya Pandian, PhD, MBA, MSN, RN, associate dean for graduate education and professor of nursing in the department of otolaryngology– head and neck surgery at Penn State College of Medicine in Hershey, Pa., and an adjunct professor at John Hopkins University School of Nursing in Baltimore, recalled when a tracheostomized patient in the intensive care unit (ICU) became increasingly agitated during routine airway care and tracheostomy management. “The patient began making verbal threats toward nursing staff and respiratory therapists, escalating to aggressive gestures when suctioning and humidification adjustments were attempted,” Dr. Pandian noted. “Importantly, this was not a life-threatening airway emergency, but rather routine care that could be paused safely.”

“The bedside team immediately shifted focus from task completion to safety. Staff used calm, clear communication, stepped back to reduce stimulation, and avoided physical confrontation. The charge nurse and ICU leadership were notified promptly, and hospital security was engaged to provide a visible but non-confrontational presence. Care was temporarily paused, and the plan was reassessed collaboratively with nursing, respiratory therapy, and the medical team,” Dr. Pandian continued. “Leadership reinforced that staff safety was the priority and supported the decision not to proceed with non-urgent interventions until the environment was safe. The patient was later re-approached with additional support, clear behavioral expectations, and a modified care plan that included additional staff presence. This experience reinforced for the team that early escalation and institutional backing are essential, and that clinicians should never feel compelled to ‘push through’ unsafe situations to complete routine care.”

System-Level Protocols

“Management relies on structured, system-level protocols rather than individual discretion,” Dr. Pandian said. “Common elements include clearly articulated patient behavior expectations, early identification of concerning behaviors in the electronic health record, predefined escalation pathways, and ready access to hospital security and risk management. Importantly, these protocols emphasize team activation (front desk staff, nurses, physicians, administrators, and security) so responsibility does not fall on a single clinician.”

Michael J. Brenner, MD, an associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor, has encountered a patient who threatened violence. The patient, with a traumatic brain injury that required revision surgery, “had been off his usual medications and became agitated when he learned there would be a significant wait for a surgery date,” Dr. Brenner said. “Our first step was to slow the interaction and reduce triggers. I enlisted the patient’s spouse, who proved to be a critical ally in calming the situation, while our staff discreetly activated security protocols. The response was calm, coordinated, and team-based, prioritizing safety without escalating confrontation. Some would have dismissed such a patient from their practice, but after partnering with other professionals, we were able to safely provide him the necessary surgical care.”