206 De-escalation (Staff (Training (Verbal loops (listens to pt (validates…
Tolerant of rapidly changing patient priorities
Tolerant?? of agitated patients
Enjoys dealing with them???
Recognise and control counter transference
Clinician must be aware of their own vulnerabilites
Client may critisise those vulnerabilites
Avoid being defensive
Know their limits with patients
When to seek extra help
Natural skill for de-escalation?
Can be learned though
Positive regard for pt
pt doing best he can under the circumstances
inability to conform with what is expected
Lack of skills in getting their needs met
practice on difficult pt's who are not agitated daily
listens to pt
clinician states what he wants pt to do
Loop repeats after pt responds
May take a dozen times before pt responds/dont' give up early
Time for de-escalation varies on the setting
BETA De-escalation less than 5 mintues?
Continue if pt not showng signs of further escalation/moving towards violence
Non verbal msg - violence will not be accepted
4-6 members: nurses, clinicians, technicians, police, security
Behavioral Activity Rating Scale
Difficult or unable to rouse
Asleep but responds verbal or physical
Overt physical or verbal activity/calms down with instruction
Extremely active, not requiring restraint
Violent, requires restraint
Overt Aggression Scale
Scale for the Assessment of Aggressive and Agitated Behaviours
Before arrival / on presentation
Staff Observation Aggression Scale
4 Reasons to use
Restraint reinforces pt idea that violence is necessary
low restraint/quality indicator?
Based on what evidence?
Less injury staff/pt
restraint/longer hospital stay?
10 Domains of de-escalation
Lazare's method/35 yrs ago
Avoid Dominant submissive
Help pt calm himself
Form of treatment
repetitive/non goal directed
Fiddling with clothes/objects
Heightened response to stimuli
Link to aggression not established?
Are they willing and able to engage?
Or unable to engage in conversation?
New or repeated violence about to occur
Vastly different management plan required than de-escalation
No need to wait for etiology
Immediate intervention to control symptoms
Non verbal communication?
Need to get Pt to become active partner in their treatment
Access to exits
Prefer not to / pick up and throw
Avoid extremes of:
Minimizes abrasive sensory stimulation
Weapons: pens, sharp objects, table lamps - remove
Types of aggression
Behaviour of getting needs met by violence
Defensive/avoid being hurt
Plenty of space
Do not initimidate
match pt pace
Wants to be heard/feelings validated
Agree in Principal
Agree in probability
Agree in truth
repeat the loop
Looking for excuses to go off to let off steam
Enjoy creating fear/confusion
Feign attacks to initimidate
Give them choices
Broken record/return to choices
Let them know you will work with them/only if they co-operate?
Set firm limits
Restraint if limit is violated
Tens domains of de-escalation
Respect personal space 2. Do not be provocative 3. Establish verbal contact 4. Be concise 5. Identify wants and feelings 6. Listen closely to what the patient is saying 7, Agree or agree to disagree 8. Lay down the law and set clear limits 9. Offer choices and optimism 10. Debrief the patient and staff.
Monitor own emotional/phsiological response/stay calm
Few/lack descriptions of specific techniques/efficacy
Safety of Patient
Safety of others
Help pt manage emotions/distress
Avoid the use of restraint
Avoid coercive interventions
Emergency Psychiatrists limited
Emergency Physicians more off
Rapid Assessment required/make a decision
Increased length of stay?
Decreased Hospital Admissions
Prevents longer hospitalization
Work on diagnosis
Many pts/too little time
prematurely use medication
Dismissive/rejecting/humiliating to pt
Need more staff and more time
How do you decide if de-escaltion will work?
Does not work for everyone
Pt active partner/treatment