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124 Prevent De-escalate (Recommendations (Barriers to conducting RCT (Need…
124 Prevent De-escalate
Practice Standards
Based on Evidence that it causes trauma
No evidence that anything else works
Keeps pt safe from harming themselves or others physically at the time.
Wishes to reduce seclusion and restraint
Is there evidence to suggest we are using seclusion and restraint unnecessarily?
Other articles state if they can't be de-escalted there is a place for seclusion and restraint
If implementing an intervention
before and after studies show reduction
Implies seclusion/restraint are being used unnecessarily
or a control study shows a reduction in the group that received the intervention
Implies seclusion/restraint are being used unnecessarily
Are their limitations on the use of the intervention
Time/Staff/Money?
Do ED staff have the time to lose a staff member to a full day of de-escalation?
How do we weigh up the pros and cons?
Time/Staff/Money vs Trauma prevention by reducing Seclusion/restraint
Whose fault is it that the pt is faced with seclusion?
Does taking drugs make it the pt's fault?
1 more item...
Risk Assessment
Multimodal Interventions
In line with 6 Core Strategies
National Association of State Mental Health Program Directors
Leadership/organisational change
Use of data to inform practice
Workforce Development
Seclusion/restraint prevention tools???
Risk assessment
Milileu based changes/sensory rooms
Staffing changes/increased staff/patient rations
Staff training programs
Interpersonal communication
Reduced seclusion/restraint
Peer based interventions
Consumer roles
De-briefing techniques
reduced seclusion time/restratint time
low soe
Seclusion/Restraint
10% - 30% adolescents, adults, elderly
Prevent Aggression from starting
Supportive/Non confrontational Language
Verbal De-escalation techniques
Cognitive Behavioural Techniques
Pharmacologic intervention/Psychiatric Illness
Recognition of triggers for aggression
Risk Assessment?
Low SOE
Reduction of use of seclusion/restraint
Decreased subsequent aggressive incidents
Reduced forced injection
Reduce Aggression once started
Already actively aggressive
Seclusion with or without restraint
Restraint
Alternative strategies????
Emergency Response team???
Pharmacolgical interventions to reduce agitation
This study
Risk Assessment
Multimodal Programs
Enhanced Admin Review???
Pts with high restraint use
Staff training re: difficult behaviour
Environemental
Equine assisted therapy???
Insufficient evidence
Group psychotherapeutic interventions
Diminish precursors of active aggression
Equine assisted therapy
Insufficient evidence
Medication Protocols
Used to de-escalate active aggression
Staff Training
New Sklls
Prevent/de-escalate aggression
Promote staff attitudes
Recommendations
Risk Assessment for violence on every pt/not just those who are aggressive
How often?
Needs a well validated assessment?
Is one tool better than another at risk assessment?
What are the measurement capabilities of these tools?
Multimodal intevetntions
What exactly?
Consistent with the six core strategies
Too broad? which one of the six is more effective than the others?
Interventions not clearly described
Can't reproduce and confirm results if don't know exact details of the interventions?
How relevant when based on findings outside the USA?
Should impmementing these be delayed until more evidence is on the table?
Does the role of Quality measures prevent the use of such interventions based on the low quality of evidence?
Barriers to conducting RCT
Obtaining informed consent
Limited funds supporting such research
Lack of well designed, adequately powered, properly analyzed comparative trials.
Need comparisons between particular interventions instead of just against usual care
differential effectiveness
justify resource costs/implementation
acceptablity, feasibility, sustainability into designs
Need to report on consistently defined meaningful outcomes
valid measures of aggressive behaviour
valid measures related to seclusion/restraint
Number of per month
Length of time spent in seclusion? etc?
Long term outcomes
Pt centered
Health related quality of life
Pt perspectives of harm
pt treatment perspectives - missing from literature
Modifying factors?
Age, sociodemographic, econnomic, diagnosis, coexisting conditions, explicit treatment components
Potential Harms and Costs - unknown?
Implementing risk assessments
Limitatioins
Adults in acute care settings only
Left out chronic care and residential settings
No children/ adolescents
Nothing on improved qulaity of life (outcome)
NOthing on improved therapeutic relationships (outcome)
We excluded studies focused on reducing agitation
Agitation is perhaps a precursor to aggression
Overlooking this data is significant
Need to explain how agitation leads to aggression?
Why
treat pts with dignity
Clinical mandate: Find evidence based solutions
To guide policy/decision making
Legal liability
Currently no definitive guidance?