Use these de-escalation techniques to maintain staff and patients protected

Roppolo works within the emergency department at Parkland Hospital and Children’s Medical Center and is a professor within the Department of Emergency Medicine at UT Southwestern. The Parkland Emergency Department is one in every of the busiest emergency departments within the country, with over 240,000 patient visits per yr. According to Roppolo, a typical scenario often involved the patient’s violent rage escalating and a number of other staff members and security having to carry him all the way down to administer sedative medications. Restraint and drugs were often the primary line of defense to regulate highly agitated and potentially aggressive behavior. Roppolo, first writer of the review “Improving the management of patients with acute agitation in the emergency department by implementing the BETA project (Best Practices in the Assessment and Treatment of Agitation),” published last year in the Journal of the American College of Emergency Physicians Open, said she has completely changed her approach to agitated patients in emergency departments and has only witnessed one physical assault in the past five years because of it. In an interview with Nurse. com Roppolo said her turning point came after reading a series of articles titled “Best Practices within the Assessment and Treatment of Agitation (BETA),” written by experts in emergency medicine and psychiatry and published in the Western Journal of Emergency Medicine in 2012 . From the articles she learned:

• The power of de-escalation in reducing acute arousal
• Risk assessment, which should dictate the best management strategies
• The outdated “hold and med” approach should be a last resort
• How to safely control the behavior of a highly agitated patient if sedatives and tranquilizers are necessary

“De-escalation is a type of conflict resolution or crisis resolution. It is a combination of strategies and techniques used to reduce patient anxiety, agitation and aggression,” said Tiffany Carder MSN, RN, CEN, emergency services clinical nurse educator at Parkland Health and Hospital System and author of the review published in Roppolo. While there are various approaches and acronyms to help with de-escalation, Roppolo uses a common-sense approach that she has successfully implemented.

“De-escalation requires empathy, compassion, kindness, partnership, understanding and a sincere desire to help,” Roppolo said. “Try to understand why the patient in front of you is anxious and treat him as you would want to be treated if you were in his shoes.”

Patients are often scared and paranoid, so one verbal method is to repeatedly tell them that they are safe and that they want to help. According to Roppolo, nonverbal communication is just as important as what the nurse says and should convey the same message. The goal is to get the patient to a point where staff can safely provide care. However, sometimes best practices are not always followed. Australian authors 2021 newspaperIn an article published in the journal International Emergency Nursing in the article “Exploring Staff Experiences: A Case for Redesigning the Response to Aggression and Violence within the Emergency Nursing” it was written: “Our findings show that there aren’t any guidelines for: assessing the chance of patient agitation, best practices in de-escalation techniques, when exactly to call Code Black, and predetermined staff role assignments in patient immobilization.” The lack of a scientific, coordinated approach to Code Black – the name given to medical and safety staff responses to actual or potential verbal and physical aggression or violence by patients, families or other visitors towards healthcare staff – can result in confusion. “If poorly managed, this exposed medical staff, security staff and patients to serious risk and had a negative impact on staff well-being,” the authors wrote. ”

Assess your level of arousal

One of the first steps in de-escalation for nurses and other staff is to assess the patient’s level of arousal. The higher the level of arousal, the greater the risk of aggressive behavior. There are scales to measure the level of arousal, including the Behavioral Rating Scale (BARS), in which a person behaving normally is 4, mildly agitated is 5, moderately agitated is 6, and severely agitated is 7. Safety in the hospital must be ensured. According to Roppolo, patients who are severely agitated or getting worse should be contacted immediately to help them de-escalate or use physical measures. Risk assessment and de-escalation take place simultaneously. According to Roppolo, sometimes de-escalation is relatively easy. For example, patients may become slightly agitated after a long wait in the ED. Simply allowing patients to talk about what is bothering them and address the issue will likely prevent the problem from escalating. In contrast, patients who are highly agitated and cannot be calmed usually require medications to alleviate their agitated behavior and physical measures.

A de-escalation success story

Roppolo remembers a case from many years ago that convinced her that de-escalation was effective. Nurses asked for medications to control a patient’s severe agitation in the ED. The patient was brought to the hospital by ambulance from a group home and was being held down by at least five officers when Roppolo entered the room. Roppolo says that before Project BETA, she was just ordering drugs. Instead, Roppolo chose to attempt de-escalation despite the intensity of unrest.

“I walked in the door, looked at him and said, ‘I’m Dr. Roppolo, sir. I’m here to help you, and you’re safe,'” Roppolo explained.

She repeated these words and guaranteed the patient that nobody would hurt him. As a precaution, she asked everyone within the room to depart, apart from one officer. She sat near the door and much enough away from the patient that he couldn’t kick, punch, or spit on her. After five minutes of listening, Roppolo discovered that the patient’s fear and agitation were the results of the abuse he was experiencing in his group home. She said the incontrovertible fact that Roppolo listened brought the person to tears. Instead of prescribing medications and conducting extensive evaluations for his altered mental status, Roppolo called a social employee and inside two hours the patient was discharged to a brand new group home. “Most individuals who are available in agitated could be de-escalated,” Roppolo said. “Some of them are mentally ill or under the influence of alcohol and may need treatment… but at least I can get them down to a level where we can work together. They often agree to take medications orally if we give them with a sandwich or something to drink.”

De-escalation suggestions

According to Carder, there are signs that nurses can look out for that suggest that a patient or their family and friends may develop into easily offended or agitated. “Researchers have identified several behavioral signals that may be associated with potential violence,” she said. “A good tool for assessing violence is the STAMP violence assessment tool. The acronym STAMP stands for Staring and Eye Contact, Voice Tone and Volume, Restlessness, Mumbling and Stimulation. The Emergency Department at Parkland Memorial Hospital, where I work, uses this tool to screen each patient during triage. The screening test is positive if one of the behaviors is observed. Nurses at Parkland Health and Hospital System are trained in de-escalation using Satori Alternatives for managing aggression, which teaches both verbal and physical de-escalation strategies as well as self-defense techniques. “Nurses also receive badges that have the STAMP tool and de-escalation techniques,” Carder said. According to Carder, specific de-escalation strategies that nurses can practice include:

• Stay two arms length apart.
• Maintain a relaxed posture and appearance.
• Speak in a peaceful voice along with your hands visible.
• Confirm what the patient says.
• Don’t threaten.
• Set limits.
• Don’t use medical jargon.
• Don’t judge.
• Show empathy.
• Use this patient’s name.
• Make peace with silence.
• Do not argue.
• Define the results of behavior.
• Be respectful.
• Don’t answer inappropriate questions.
• Treat with dignity.
• Use Trauma-informed careand consider the entire person: past and present experiences.

Take courses on related topics:

Adverse childhood experiences (ACEs) have a long-lasting negative impact on adult health in the shape of dangerous behaviors and chronic diseases. Health care providers have a novel opportunity to handle these risk aspects through screening, confirmation, and referral for treatment. This continuing education program reviews research and science on the impact of childhood trauma on adult health and well-being, explains methods to detect risk aspects, and describes methods to promote healing and resilience through trauma-informed care.

The purpose of this course is to tell nurses in regards to the potential dangers of immobilization devices and methods to reduce their use. The course reviews the regulations and standards of care regarding using restraint devices, but emphasizes alternatives.

Violence in healthcare settings reflects chaos within the broader work environment. Not only do experts agree on the extent of violence in health care settings, but additionally they agree on the most effective treatment for it: education and prevention. Nurses increase their awareness and expertise in coping with violence in skilled settings by learning to discover risk aspects and warning signs and using interventions that may protect their patients and themselves from harm.