Verbal De-escalation

Verbal De-escalation BETA Healthcare group Emergency Medicine Council 2018

Objectives • Examine common drivers of patient agitation • Define the role of logistics when approaching an agitated patient • Explore communication techniques most effective in management of agitated patients • Recognize when patients should be restrained vs. allowed to elope

The following materials are taken directly from:Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workshop West J Emerg Med. 2012;13(1):17-25 Janet S. Richmond, MSW Jon S. Berlin, MD Avrim B. Fishkind, MD Garland H. Holloman Jr, MD, PhD Scott L. Zeller, MD Michael P. Wilson, MD, PhD Muhamad Aly Rifai, Md, CPE Anthony T. Ng, MD, FAPA

Agitation An acute emergency condition requiring immediate intervention to control symptoms and decrease the risk of injury.

A Behavioral Syndrome • May have several different underlying emotions • Actions: Usually repetitive and non-goal directed such as • Tapping foot • Wringing hands • Pulling at hair • Fiddling with clothes or other objects • Thoughts: Repetitive and verbalized: • “I’ve got to get out of here. I’ve got to get out of here…” • Heightened irritability and responsiveness to stimuli

Logistics – Respect Personal Space • Approaching the patient • Maintain at least 2 arm’s lengths between you • Sitter should be positioned closest to the exit • Never let the patient get between you and the exit • Door should remain open; never locked • Mechanism to notify nurse of need to be relieved • Do not leave the patient’s room until your replacement arrives

Why is Space so Important? • Previous experience of personal trauma • Homeless person may be sensitive about protecting his belongings • Previous sexual abuse may be sensitive about removing clothing. Feelings of vulnerability and humiliation

Alleviating Their Fear • Demonstrate open body language • Hands unclenched and visible • Avoid folding arms or turning away • Knees slightly bent • Stand at a slight angle to avoid appearing confrontational • Avoid excessive direct eye contact

Behavioral Activity Rating Scale (BARS) • Difficult or unable to rouse • Asleep but responds normally to verbal or physical contact • Drowsy, appears sedated • Quiet and awake (normal level of activity) • Signs of overt (physical or verbal) activity, calms down with instructions • Extremely or continuously active, not requiring restraint • Violent, requires restraint

Escalation Cycle Fight or Flight Lost opportunity Opportunity Raised Voice Caustic Tones Pacing Tapping Fingers Frequent questions Look at watch Throwing things Fists clinched Pushing Yelling/cursing Threats of physical harm Spitting Hovering Cursing Loud insults Demand to speak with supervisor Threaten legal action Frown Sigh Facial Grimace

Four Goals when Working with Agitated Patient • Keep the patient and others safe • Help patient manage his emotions/distress and maintain or regain control of his behavior • Remain calm; check your emotions and fear before approaching the patient • Avoid using restraints when possible • Avoid coercive interventions Caution: Shortcuts (such as using restraints or coercion) may seem more expedient but will cost you in the long run

Three Step Approach to De-escalation • Verbally engage the patient • Listen to the patient • Establish a collaborative relationship • Find way to respond that agrees with or validates the patient’s position • State what you would like the patient to do • May need to repeat a dozen or more times- DON’T GIVE UP • Verbally de-escalate the patient out of the agitated state • Generally takes less than 5 an as much as 10 minutes Goal: Help the patient calm himself

Verbal Communication • Verbal interaction is best restricted to one person • If person responsible for de-escalation is not the first person of contact; promptly bring in the designated person • Introduce yourself • Provide your name and what you do at the hospital • Explain you are there to keep him safe and make sure no harm comes to him or anyone else in the department • Orient patient to where he is and what to expect (may need to repeat several times) • Ask patient his name if not known

Verbal Communication • Be concise • Short sentences, simple vocabulary • Reduces risk of confusion leading to further escalation • Allow patient time to process before adding more information • Persistently repeat information to the patient until it is heard • Especially when making requests, setting limits, providing choices, or proposing alternatives

Identify/Acknowledge Wants and Feelings • Sad people seek hope • Fearful people seek to not be harmed • Aggressive people are seeking something specific you will need to inquire to discover what it is by asking • “I want to get out of here!” • “I want that for you too. I don’t want you to have to be here any longer than necessary. How can we work together to help you get out of here?”

Use Active Listening Skills • Use body language to show you are listening (nod head) • Be in the moment, really listening to what the patient is saying • Can you paraphrase what the patient said and get it right? • Tentatively share your understanding of what was said, ”Tell me if I have this right…” • You don’t need to agree with the patient; just understand • Avoid making promises you cannot keep

Agree Where You Can • Agree with the objective facts [If feeling violated with all of the people in the room upon arrival] • “Yes, there were a lot of people in here touching you. I can understand how that could make you feel that way.” • Agree with the principle of what was said [If upset with the way he was treated] • “I believe that everyone should be treated with respect.” • Agree with the odds [If individual upset by the wait and states anyone would be upset] • I’m sure there are other patients who would be upset also.”

Set Limits • Speak in matter-of-fact tone and respectfully • “Hurting yourself or anyone else is not okay.” • “You could even get arrested if you try to hurt anyone.” • Tell patient when behavior is frightening and match with empathetic statement. • “I’m here to help you, not to hurt you. I can see that you are upset; nevertheless, when you curse and spit at me, it frightens me and makes it harder for me to pay attention to what is bothering you. I need you to stop cursing and spitting so that I can help you.”

Offer Choices when Available • When patient is on edge of “Fight or Flight”, empower him by providing alternatives to violence or elopement. • Include acts of kindness: blanket, phone access, snacks, etc. • Never promise what you can’t deliver (take him out to smoke)

Medication Discussion & Persuasion • Goal of medicating agitated patient is to calm her so that she can participate in decisions of her care • Gradually bring up the subject: • “What helps you at times like this?” • “I think you would benefit from medication.” • “I really think you need a little medication.” • “You are in a psychiatric emergency. I’m going to order you some emergency medication. It works well and it’s safe. Would you prefer a pill or a shot?” • “I’m going to have to insist.”

Tips • Try to allow the patient to bring up the discussion of medications • Ask the patient what medication has helped in the past • Consider: • “I see that you’re quite uncomfortable. May I offer you some medication?” • “It’s important for you to be calm so that we can talk. What can we do to help you calm down? Would you be willing to take some medication?”

Consequences of Alternate Approach • Physical intervention by staff reinforces patient’s thoughts that violence resolves conflicts • Patients requiring restraints have greater likelihood of in-patient admission and longer length of stay • CMS and TJC frown on high restraint rates • Patient and staff have lower risk of injury when physical altercations are avoided

Hand-offs and Huddles • Establish up front how you are to communicate with the nurse assigned to the patient • Use SBAR to report off to oncoming staff • Include the patient’s most current agitation score and what works best to help de-escalate the patient • Also include any known “triggers” that escalate the patient • Introduce the oncoming staff to the patient and say good-bye to the patient

Trained Response Staff • Should patients agitation advance to violence, a de-escalation team consisting of 4 to 6 trained staff made up of nurses, clinicians, technicians, police and security officers may be needed • Team will continue to provide for verbal de-escalation • Prepared to physically intervene if necessary

Hospital’s Duty to Protect • The hospital has a duty to protect individuals who are at risk of harming self or others. • Early intervention through verbal de-escalation is essential • Medicate if necessary to calm the patient to allow for patient participation in their care • Restrain if necessary to keep patient safe • Use agitation scale to help identify when it is safest to do so

What if Patient Attempts to Leave? • If patient cannot be stopped without putting others in risk of harm; allow the patient to go • Immediately notify law enforcement and provide description of: • Appearance • Clothing • Direction last headed • Specific concerns for safety of patient or others • Possible target if patient is homicidal

Patient Elopement • Immediately notify unit staff and security to assist with searching for patient • Search unit thoroughly • Check patient ID bands to ensure correct patients are in assigned rooms • Check closets, bathrooms, supply rooms, and carts • Look for abnormalities such as missing ceiling tiles into vents • Security will search outside of department • If unable to locate within 5 minutes, notify law enforcement

Post-care Debrief • After any involuntary intervention • Encourage staff to talk about the event • What happened? • What went well? • What didn’t go as expected? • Recommendations for improvement • If staff was emotionally or physically traumatized during the encounter; additional resources may be required.

Questions?

Verbal De-escalation