De-escalation Techniques Research Articles

Wire Escalation And De-escalation Techniques in Antegrade and Retrograde Approaches to Chronic Total Occlusion Percutaneous Coronary Interventions

Coronary chronic total occlusions (CTO) are frequently identified during coronary angiography and remain the most challenging subset of coronary artery lesions to treat; however, advancements in techniques and materials have greatly improved success rates. Various crossing algorithms have been developed to standardise the approach to CTO interventions based on angiographic criteria. Antegrade wiring is typically the initial strategy of choice, particularly in cases of short and straight CTOs with tapered proximal cap. Similarly, retrograde crossing can be achieved through retrograde wiring, although this approach has a very low success rate. This review aims to outline how to perform a CTO analysis, clarify the fundamental features of guidewires and provide insights into both antegrade and retrograde wire-based approaches.

Exploring the Relationship Between Officer Safety and De-escalation in a Simulated Crisis Encounter

Recently, there has been an increase in media attention and public interest in the use of de-escalation by police officers; however, concerns have been raised regarding potential risks to officer safety. The literature examining the relationship between officer safety and de-escalation is sparse. Drawing on performance assessments of 122 active-duty police officers during a realistic scenario with a person in crisis, the relationship between de-escalation techniques and officer safety was examined using multiple regression analysis and multiple correspondence analysis; a positive (but imperfect) relationship between de-escalation and officer safety was found. The association between relational de-escalation strategies (e.g., active listening, displaying empathy) and officer safety appeared to be strong; less so for tactical de-escalation strategies (e.g., pre-planning, self-control). However, it is unclear whether relational strategies increase officer safety, or whether greater officer safety allows relational strategies to be used. Future research is needed to understand this relationship and determine whether similar results are found in more naturalistic settings.

Violent encounters on the front line: Sequential explanatory mixed-methods investigation of physical violence factors in the prehospital setting

ObjectiveWorkplace violence (WPV) is an important issue in prehospital care, especially for emergency medical technicians ( EMTs) who are at increased risk of physical violence due to the nature of their work. This study aimed to shed light on the specific factors that contribute to the underlying causes of physical WPV in the prehospital context through direct experience and insight into the work of EMTs.MethodsSequential explanatory mixed methods were applied in five western provinces of Iran from 2022 to 2023. In total, 358 EMTs that met the criteria for the quantitative phase were selected using a multi-stage clustering method. In the quantitative phase, the researchers used a questionnaire on workplace violence in the healthcare sector. Based on the results of the quantitative phase, 21 technicians who had experienced physical violence in the past 12 months were invited for in-depth interviews in the qualitative phase.ResultsThe average age of the EMTs was 33.96 ± 6.86 years, with an average work experience of 10.57 ± 6.80 years. More than half (53.6%) of the staff worked 24-hour shifts. In addition, most EMTs were located in urban bases (50.3%), and 78 (21.8%) reported having experienced physical violence. No significant correlations were found between the demographic characteristics of the technicians and the frequency of physical violence, except base location in the last 6 months. The qualitative study also created one theme (the complexity of WPV in the prehospital setting), four categories, and ten subcategories.ConclusionThe study’s results emphasize the need for comprehensive WPV factors in the prehospital setting. These factors can lead to identifying and improving strategies such as organizational support, improving communication and collaboration between responders, and training in de-escalation techniques. In addition, it is crucial to address the root causes of WPV such as poverty and lack of education in the community to create a safer and more supportive environment for patients and staff.

Using simulated patients to teach de-escalation during Registered Nurses' onboarding

BackgroundWorkplace violence and aggression toward healthcare professionals are concerning trends in the industry, with increasing incidents over the last decade. The COVID-19 pandemic put additional stress on health systems, healthcare workers, patients, and family members. These additional stressors resulted in increased aggressive behaviors. Education and training on de-escalation techniques is paramount to increased safety of health professionals and patients. Nursing education programs and hospital orientation programs often lack de-escalation training. MethodsFrom January to October 2023, 102 nurses participated in a de-escalation simulation encounter. Quantitative and qualitative data was captured via Redcap survey. Facilitators tracked behaviors of the simulated patients and reactions of the nurses, in real-time, using a survey designed by the education team. Participants completed a post-survey which elicited information about prior de-escalation training and application of skills learned during the de-escalation simulation encounter to future practice. ResultsSixty-five percent of new graduate nurses revealed that they had some form of de-escalation training most of which was provided through a lecture (36%) or online module (19%). Following participation in the simulation encounter, 98.5% of participants felt better prepared to manage an escalating patient/family member situation. Structured debriefings identified educational gaps regarding hospital resources, behavioral strategies for averting escalating incidents, methods for maintaining safety, and discreetly seeking assistance. ConclusionThe simulated patient training offered participants an opportunity to apply de-escalation techniques in a safe environment. Targeted de-escalation training using simulated patients increased the authenticity and realism of the immersive experience and resulted in enhanced de-escalation skill development in new hire nurses.

2241 ‘You learn by doing, and by falling over’: a simulation-based approach to frailty, falls and fractures.

Abstract Background Studies show that newly qualified doctors feel unprepared for clinical practice in several key areas in the care of older people, despite older people occupying two thirds of inpatient beds [1,2]. Grounded in experiential learning theory, simulation has been hugely effective in undergraduate education in geriatric medicine [3]. We aimed to evaluate a novel simulation series exploring practically challenging aspects of geriatric medicine, such as ‘silver trauma’ and using de-escalation strategies in the management of delirium. Methods Using quality improvement methodology, we developed two inpatient simulation scenarios for fourth-year medical students on their geriatric medicine clerkships. The scenarios (managing delirium and post-falls assessment) are commonly encountered during on-call shifts, with learning outcomes aligned to Outcomes for Graduates. Our initial cycle involved eight students piloting the two scenarios and evaluation tool. Using their feedback, we will iteratively improve the methods and evaluation before repeating and obtaining pre- and post-simulation data on students’ ‘preparedness for F1’. Results Following the pilot, 100% of participants agreed that they felt more prepared for clinical work in geriatrics as an F1 doctor. 12.5% felt confident assessing a patient following a fall pre-session, which increased to 100% afterwards. Confidence in using de-escalation techniques in managing delirium improved from 50% (pre-) to 100% (post-session). Common themes in free-text feedback were that the simulation felt realistic and effectively tested prioritisation. Conclusion Our work highlights the merits of using simulation in geriatric medicine to help undergraduates prepare for the complexities and uncertainty involved in caring for the ageing population.

The Guardians of the Streets: Frontline Law Enforcement Officers

This study explores the intricate realm of frontline law enforcement personnel, the sentinels who patrol the streets and deal with the day-to-day challenges of maintaining community safety. The aim is to investigate the obstacles and prospects they face, with a particular emphasis on mental health, de-escalation strategies, and community involvement. Principal Subjects: The Effects of Prolonged Stress: We will look at how common stress and trauma-related illnesses like depression and PTSD are in front-line law enforcement personnel. De-escalation Techniques and implicit bias the study will examine how well de-escalation training programs reduce the need for force as well as how implicit bias affects officers' judgment when they engage with members of the public. Establishing trust through community Policing. This section will look at ways to help frontline police and the communities they serve build strong bonds, with an emphasis on underserved areas. Principal Arguments Frontline officers' mental health is greatly impacted by ongoing stress. Officers who receive specialized de- escalation training may be better able to settle disputes amicably and use less force. Officers' interactions with the public can be less affected by unconscious stereotypes when they get implicit bias training. Building trust is a key component of effective community policing tactics that can boost public safety and strengthen ties within the community. Significance by looking into these topics, the research hopes to. Develop efficient stress management methods that will improve officer well-being. Implementing evidence-based de-escalation training will improve public safety. improved community-police ties by implementing programs aimed at fostering trust. Target audience: A wide range of people are intended to read this research, including Policymakers and law enforcement leaders who can put the findings into practice by implementing better policies. mental health specialists who are capable of creating focused interventions to enhance the wellbeing of officers. Community organizations trying to bridge the gap between law enforcement and the public. Additionally, the general public is interested in learning more about the opportunities and difficulties that frontline law enforcement officers encounter.

Improving Safety and Satisfaction in the Safety Monitoring Unit.

BACKGROUND: The safety monitoring unit (SMU) is a 4-bed unit designated for patients who require continual observation. Most experience some form of dementia, and agitation and aggression are not uncommon. When deescalation techniques do not work, request for help may be necessary. Referred to as Security Alert: Behavioral Assist (SABA), this system-wide message requires response from designated personnel. An increase in SABA events prompted this quality improvement project. METHODS: A survey sent to all unit staff members identified a need for specialized training on the care and management of SMU patients. Education on dementia care and deescalation techniques was provided by a certified dementia specialist and a psychiatry advanced practice registered nurse. Staff expressed a need for defined SMU admission criteria and the establishment of patient care guidelines. Patient care guidelines were developed. A structured schedule was implemented, and dedicated staff were hired to provide familiarity for patients. RESULTS: A postproject survey indicated a nonsignificant increase in staff satisfaction. Security Alert: Behavioral Assist events in the SMU decreased from an average of 3.6 to 1.75 episodes per month. CONCLUSION: Caring for SMU patients creates unique challenges to staff. Staff confidence and satisfaction were higher after implementing new SABA policies. This project could be replicated on similar units with ongoing leadership support and staff education.

Finding the Right Setting for the Right Treatment During the Acute Treatment of Individuals with Schizophrenia: A Narrative Review and Clinical Practice Guideline.

Schizophrenia is most times a chronic and often debilitating illness associated with poor mental health outcomes. Early and effective treatment of schizophrenia in the most appropriate setting can make a significant difference in the long-term recovery. The aim of this narrative review was to provide suggestions and recommendations for effectively managing patients with schizophrenia during acute exacerbations and to enhance awareness and skills related to personalized medicine. A panel of academics and clinicians with experience in the field of psychosis met virtually on July 13th 2023 to narratively review and discuss the research evidence and their clinical experience about the most appropriate acute treatments for patients with schizophrenia. This manuscript represents a synthesis of the panel analysis and discussion. First contact is very important for service users, as is finding the most adequate treatment setting. If patients present to the emergency department, which may be a traumatic setting for service users, a dedicated environment with adequate space and specialized mental health support, including personnel trained in de-escalation techniques, is recommended. A well-connected continuum of care is strongly recommended, possibly with seamless links between inpatient units, day hospital services, outpatient facilities and rehabilitation services. Ideally, this should be structured as part of a coordinated step-down service line. Treatment challenges include suboptimal response, side effects, and nonadherence, which is reduced by the use of long-acting injectable antipsychotics. Individual circumstances, including age, gender, and presence of hostility/aggression or self-harm, cognitive impairment and negative symptoms, comorbidities (depression, substance use disorders) or associated symptoms (anxiety, insomnia), should be considered when selecting the most appropriate treatment for the acute phase of schizophrenia. Efficacy and feasibility, as well as acceptability and tolerability of treatments, require joint consideration from the early stages of schizophrenia, thereby enhancing the possibility of improved short- and long-term outcomes.

Undesirable Customer Behaviours in Banking and De-escalation Techniques

Objectives: The study has three objectives; to identify the types of undesirable behaviour, determine categories of undesirable customer behaviour, and reveal the way of dealing employees with undesirable customer behaviour. Methods: The critical incident technique was utilized in analysing interviews with frontline banking employees and managers in Saudi Arabia. Thematic analysis was chosen to analyse the data. Results: It shows that some customers abuse employees verbally, speak loudly, show contempt, post their frustrations on social media, take photos or videos of employees, and try to harm employees by raising false complaints. The types of undesirable customer behaviour can be divided into three categories, namely, behaviours that harm the employees, behaviours that waste employees' time, and behaviours that frustrate both the employees and the other customers. Conclusion: The study concluded that the types of undesirable customer behaviour are different from one sector to another, and it may not occur in another sector besides the banking sector, and the diversity of undesirable customer behaviours creates a barrier to developing a tactic for each behaviour, and the undesirable customer behaviour can be grouped into three categories according to its impact.

Advanced paramedics' restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation.

Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.

Reducing use of seclusion on a male medium secure forensic ward

The reduction of restrictive practices is a priority for mental health inpatient services. Often such practices are considered to increase patients’ feelings of anger, loneliness, hopelessness and vulnerability. Moreover, such...

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

IntroductionThe burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk...

Assaults and Microaggressions Against Psychiatric Residents: Findings from a US Survey.

Psychiatric physicians may experience higher rates of assault than those in other fields. For many reasons, residents may be especially vulnerable. This study updates rates of assaults among US psychiatry residents as well as the reporting rates and emotional effects of these incidents. Little data exists to examine rates of microaggressions against psychiatry residents. A cross-sectional online survey was distributed through a national residency database via a snowball-sampling approach between June and September of 2021. The questionnaire asked about experiences of verbal, physical, and sexual assaults, as well as microaggressions and their impact. Descriptive analyses of the obtained data were conducted. The survey was completed by 275 psychiatry residents from 29 states (63.6% women). At least one form of assault was experienced by 78.9% of participants with 74.5% experiencing verbal, 22.2% experiencing physical, and 6.2% experiencing sexual assault. At least one type of microaggression was experienced by 86.9% of trainees. Elevations in PTSD scores were seen in residents who identified as women and non-White and those physically injured or sexually assaulted. While 92.7% of residents stated their program provided training about assault, 25% of residents indicated they had no training on recognizing and responding to microaggressions. Psychiatric residents experience widespread assault and microaggressions in the clinical setting but often do not report them. Due to the ubiquitous nature of these events, programs should provide training about early recognition and de-escalation techniques for agitation, responding effectively to microaggressions, and the importance of reporting events.

From pain compliance to leverage-based control: Evidence of reduced use of force severity and injuries following police training

Abstract Training is a frequently requested response to contentious police use of force incidents. Yet limited research evaluating use of force training has been conducted and most has focussed on officer perceptions of training, as opposed to the impact of training on use of force in the field. We address this gap through evaluating a 120-h Response to Resistance and Aggression training developed and implemented by the Saint Paul Police Department. By integrating leverage-based control and de-escalation techniques, this program sought to reduce the severity of force used by police officers. Results from machine learning models indicate that training did reduce reliance on pain-compliance techniques. Adjusting for factors including encounter, subject, and officer characteristics, training was associated with an estimated 3.3 percentage point reduction in officer injuries and a 1.3 percentage point reduction in significant subject injury. These findings contribute to the evidence base surrounding effective police training programs.

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial.

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial.

“I didn't know it would be like this”: Professional Preparation for Social-Service Information Work in Public Libraries

Recent semi-structured interviews with 28 librarians and branch managers on the placement of social workers in public libraries revealed a need for library and information science (LIS) programs to better prepare students for their role as social service information providers and to provide models for working with and supervising social workers in the library. It is clear that libraries are experiencing increasing demands to respond to the social-service information needs that users bring to the library, and the importance of libraries to communities in times of uncertainty and crisis is clear. In response, some libraries are including social workers on staff, but this trend does not completely relieve librarians of the need to serve the public's social-service information needs. LIS students need to understand the professional boundaries of librarianship and social work and to develop the ability to feel confident in their interactions with users who have been traumatized, are in crisis, or are struggling with challenges such as the need for credible health information; home and food insecurity information; legal aid; access to the Internet for individuals and families from low-income situations; accessible adult education programs; and more. Interview participants offered a number of suggestions for how to incorporate social work concepts into LIS education and asked for several specific skills such as training in mental-health first aid, de-escalation techniques, and greater knowledge of social-service resources.

Antistaphylococcal Efficacy of Cefepime, Meropenem, and Piperacillin-Tazobactam in Patients with Polymicrobial Infection with MSSA Bacteremia or Pneumonia

There is a paucity of literature describing de-escalation techniques in patients with polymicrobial infections with one offending organism being methicillin-susceptible Staphylococcus aureus (MSSA) being treated with β-lactam therapy. The purpose of this study is to determine treatment outcomes for patients with polymicrobial infections with MSSA bacteremia or pneumonia who are treated with cefepime (FEP), meropenem (MEM), or piperacillin-tazobactam (TZP). This trial design represents a retrospective observational three-group comparison study of patients at a community teaching hospital system. Patients reviewed included those who had a MSSA bacteremia or pneumonia in addition to a confirmed polymicrobial infection or presence of a coinfection and received definitive therapy with FEP, MEM, or TZP. The primary outcome is defined as the resolution of fever of ≥100.4°F, hypothermia (≤95°F), leukocytosis (WBC °>° 12,000 cells/mm3), and leukopenia with WBC °<° 4,000 cells/mm3. Secondary outcomes included duration of definite therapy, in-hospital mortality, hospital and ICU length of stay (LOS), 30-day readmission rates for a presumed infection, and hospital-acquired Clostridioides difficile infection (HCDI). From August 1, 2016, to August 30, 2019, 45 patients met eligibility criteria. There were no observed differences in primary endpoint ( p = 0.65) or secondary endpoints, i.e., in-hospital mortality ( p = 0.10), hospital LOS ( p = 0.75), ICU LOS ( p = 0.53), 30-day readmission rates for presumed infection ( p = 0.07), or HCDI ( p = 0.34). There was no difference in treatment success with FEP, MEM, or TZP for polymicrobial infections with one offending organism being MSSA. Due to the lack of evidence in this unique patient population and observed results of our study, randomized studies are warranted to determine appropriate therapy in this complex patient population.

Perceived Competence of Ground Staff in Dealing with Unruly Passenger Behavior at Manila International Airport Authority Airports

Abstract: Unruly passenger behavior poses a significant challenge to the airline industry, affecting safety, security, and customer satisfaction. Ground staff play a crucial role in managing these behaviors, and their perceived competence is pivotal in shaping passengers' overall experiences. Passengers' perception of ground staff competence depends on factors such as staff knowledge of airline policies, de-escalation techniques, and their projection of confidence in handling unruly passengers. Airlines have an opportunity to enhance ground staff competence through comprehensive training, clear policies, and a culture of support and teamwork. The study aims to assess and describe the perceived competence of ground staff in dealing with unruly passenger behavior at Manila International Airport Authority airports. A quantitative research design used a survey as the primary data collection method. Stratified and convenience sampling methods were combined to select 1,475 respondents, representing a diverse sample. Data was analyzed using mean scores, standard deviation, and variance to assess the perceived competence of ground staff. The data suggests that ground staff generally exhibit competence in dealing with unruly passenger behavior. However, competence may vary in specific situations, such as when passengers exploit minor anomalies or use their social status for additional services. Overall, ground staff are perceived as competent, particularly in handling passengers displaying potentially violent tendencies. The findings of this study reveal that ground staff at Manila International Airport Authority airports are generally perceived as competent in handling unruly passenger behavior. While competence may vary in specific situations, such as when passengers exploit minor anomalies, overall, ground staff are well-equipped to ensure passenger safety and a smooth travel experience. The study highlights the importance of ongoing investment in staff training and resources to improve the competence of ground staff in addressing unruly passenger behavior, ultimately contributing to passenger satisfaction and safety.

Relational skill training for patient engagement and the creation of a trauma-informed critical care.

Patients and families in critical care have a high likelihood of previous and re-experienced trauma. Unaddressed, physical, and psychological impacts of these traumas can worsen outcomes for patients and families. A trauma-informed care approach has been proposed for critical care; however, training programs do not include relational competencies or de-escalation techniques, risking the re-traumatization of patients and families in critical care and negatively impacting clinicians. This article describes a strategy that can be adopted by critical care teams towards the creation of a trauma-informed critical care unit including the use of a framework for relational training. Principles of relationship management and de-escalation are discussed with the use of a fictional exemplar scenario. Key messages include a call to action for relational training for care teams to enhance skilled relational engagement of patients and families. This article also highlights the foundational importance of policies supporting a trauma-informed approach in critical care.

Police Violence in Health Care Settings in US Media Coverage

Hospitals do not collect or share data tracking their policing and security activities despite their reliance on police and security personnel, including armed officers. Thus, little is known about how hospital security is associated with patient and staff safety. To examine the harms exerted by health care-affiliated police and security personnel. For this qualitative study, data were collected using a systematic Media Cloud search for US news media coverage from January 2011 to May 2022. A total of 18 987 articles on policing and hospitals were screened and a content and thematic analysis of articles that met the search criteria was conducted, which involved incidents that revealed harm to patients, patients' families, and staff. Data were analyzed from October 2022 to April 2023. Incident year, incident location (hospital name, city, state), survivor and victim characteristics (race and ethnicity, presence of mental illness), and a narrative description of the incident focusing on outcomes of harm exerted by police and security personnel in the health care setting. A total of 48 unique stories across 25 US states were included. The median (range) year published was 2017 (2009-2022). Harms reported to have been perpetuated by health care-affiliated police and security personnel were identified within 5 domains from 48 unique incidents: (1) patients shot by police or security personnel (17 patients); (2) patients subject to excessive use of force (17 patients); (3) patients arrested (7 patients); (4) patients subject to sexual assault (2 patients); and (5) hospital personnel or those considered collateral damage shot, injured, or arrested (5 individuals). Most survivors and victims were Black, although the race and/or ethnicity of involved individuals was not routinely reported across the news stories. Mental illness was the most documented medical condition among patients injured or killed by health care-affiliated police and security personnel. This qualitative study of US news media found that police and security personnel in hospitals were reported to have perpetuated harm via excessive force, sexual assaults, injuring patients and health care workers, and fatal shootings. Compounded by a lack of transparency and accountability mechanisms, this may represent an underrecognized manifestation of structural racism at the organizational level. Policy suggestions include introducing accountability measures, deescalation techniques, and removing arms from hospital security personnel to reduce harm and fulfill health care's healing mission.