De-escalation Techniques Research Articles

Care of patients with mental health issues in the emergency department: a quality improvement project.

Mental health issues have increased significantly over the past decade in the US and emergency departments (EDs) often serve as a safety net to protect and support patients with mental health issues. However, many EDs in the US are not equipped to provide the level of advanced care that patients experiencing a mental health crisis require. This article describes a quality improvement project conducted in an ED in Colorado, US, to identify and address deficiencies in the care provided to patients with mental health issues. The care of patients with mental health issues in the ED can be enhanced through measures such as implementing a validated suicide risk assessment tool, reducing ligature risks, improving the physical environment and training staff in de-escalation techniques.

Project ENHANCE: Assessing Professional Learning Needs for Implementing Comprehensive, Integrated, Three-Tiered (Ci3T) Models of Prevention.

We report findings from a multistate survey of 720 faculty and staff from 25 elementary schools in five districts across three states and geographic regions participating in an IES Network grant examining integrated tiered systems. In this preregistered study, we replicated and extended previous inquiry examining educators’ views of (1) implementation of core components of their school’s Comprehensive, Integrated, Three-Tiered (Ci3T) model of prevention; and (2) preference for professional learning (content and avenue). Results indicated more than half of respondents indicated high levels of implementation of core features of Ci3T across Tiers 1, 2, and 3. Educators reported high levels of implementation for 10 out of 19 research-based educational practices used within tiered systems with a statistically significant relation between ratings of implemented practices and the desire for support with most practices. Respondents identified their top three areas for professional development needed in the coming year as behavior deescalation techniques, small-group social skills instruction, and strategies for supporting students with internalizing behavior patterns. For potential professional learning avenues, respondents’ top ratings were in-district, during-school workshops, course for college credit on-line, teacher collaboratives/networks, and one-to-one coaching or mentoring. There were many similarities among educators’ ratings across implementation year and state. Low levels of implementation across many core Ci3T and common educational practices were reported by educators working within the most experienced schools. We conclude with a discussion of implications, limitations, and future directions.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43494-021-00049-z.

Pharmacologic restraint during ED mental health visits

In this volume of The Journal, Foster et al reported the trends and variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department. The authors noted a more than 2-fold increase in mental health visits over the past decade. The use of pharmacologic restraints during the same time period increased more than 3-fold. More importantly, they reported significant variation in the use of pharmacologic restraints across hospitals. Ideally, children with mental health concerns should be seen in emergency departments that create calming environments and by staff trained on behavioral de-escalation techniques for children.

Assessing the responses of smokers to requests to stop smoking on hospital grounds.

Fear of aggression is often cited as an issue for health service staff in approaching smokers who are breaching smoke-free policies. This study collected data to quantify the interactions between Health Promotion Service staff and smokers. The aim was to trial de-escalation based protocols for Authorised Inspectors and one for general staff with regards to the aggression risk to staff when approaching smokers within hospital grounds. The study design was a non-randomised trial with no control group. A standard protocol was developed, based on de-escalation techniques. The primary outcomes of the study were measures of aggression and smokers' compliance with instructions to extinguish their cigarette. Aggression was recorded using the Modified Overt Aggression Scale (MOAS). Two hundred interactions were conducted with smokers during business hours by Health Promotion Service staff. The first 100 interactions were based on an enforcement methodology typically delivered by Authorised Inspectors, while the second 100 interactions were based on an information and assistance methodology to reflect those that could be delivered by general health service staff. Only four instances of aggression were experienced, representing 2% of all interactions. Each of these was limited to verbal aggression. No self-aggression, aggression against property, or physical aggression was encountered. Smokers were significantly more compliant to instructions to extinguish their cigarette in the enforcement method (64%) than the information and assistance method (45%) (P<.001). Groups of smokers were more compliant than individual smokers in the enforcement method (76.3% compared to 56.5%, P<.05). This study quantifies the risk of aggression to health service staff conducting smoking compliance interactions using two methodologies. By following de-escalation-based protocols, staff can approach smokers in a low-risk manner and support smoke-free policy implementation and compliance. For general staff, the emphasis of interactions must be on providing information and assistance to smokers, not enforcement, as indicated by the reduced rate of immediate compliance, introducing an increased risk of escalation if enforcement is attempted. SO WHAT?: These protocols could be implemented by other health services or organisations that are seeking to optimise the involvement of staff in supporting smoke-free policies.

AMA Opposes Use of Ketamine, ‘Excited Delirium’ for Law Enforcement Purposes

AMA Opposes Use of Ketamine, ‘Excited Delirium’ for Law Enforcement Purposes

Choose your own adventure

Psychiatric advanced directives (PADs) are utilized by mental health patients to direct their psychiatric care including assigning surrogates for medical decision-making, listing preferred inpatient psychiatric/treating facilities, preferred medication regimens to stabilize acute psychiatric condition and to facilitate the patient's overall interaction with the mental health system. This article reviews the rationale behind PADs, how they can be utilized to reduce the need for de-escalation techniques, restraints and chemical anxiolysis by partnering with patients in the delivery of their care. This paper will also briefly address some of the practical limitations that Emergency Physicians and allied health care providers might face in attempting to honor PADs including the inability to admit to preferred facilities due to staff shortages or other issues associated with the global COVID-19 pandemic. The following core competencies are addressed in this article: Patient care, Interpersonal and communication skills, and Systems-based practice.

Exploring staff experiences: A case for redesigning the response to aggression and violence in the emergency department

IntroductionA Code Black is the coordinated response by healthcare staff and security to an act or threat of verbal and physical aggression or violence perpetrated by a patient, family member or visitor towards healthcare staff within a hospital setting. Behavioural disturbance is often verbally de-escalated by staff. However, as a last resort physical and/or chemical restraint may be necessary. Reports show that there is an increasing number of violent incidents in Emergency Departments (ED), emphasising the importance of staff training for Code Black events. This research examines the response of healthcare staff to aggression and violence in the ED, the supporting structures that manage a Code Black event and potential avenues for restructuring the response. MethodsWe used a constructivist methodology to evaluate the training needs of healthcare staff. In 2019, we interviewed 20 staff and conducted a series of ethnographic observations in EDs across four hospitals in the Western Sydney Local Health District (WSLHD) in New South Wales (NSW), Australia. We focussed on staff experiences of Code Black events and the current departmental response. Staff recounted experiences of 45 Code Black events which were collated and thematically analysed. ResultsOur findings show that there are no guidelines for: assessing the risk of an agitated patient, best practice de-escalation techniques, when exactly to call a Code Black and the pre-determined allocation of staff roles for patient restraint. Code Black response efforts lacked a systematic approach to coordinating resources and personnel, and there was confusion over the role of security. When poorly managed, this placed healthcare staff, security personnel and patients at serious risk and had a negative impact on staff wellbeing. We found training in Code Black interventions relies heavily on learning on the job from experienced staff members. ConclusionA systematic, coordinated and consistent organisational response to Code Black events is essential for the safety of ED staff. The roles and responsibilities of health workers and security require clear definition, and health workers across the WSLHD require easily accessible and repeatable experiential training in managing Code Black events.

Evaluation of a mental health first aid workshop for healthcare professionals

AimsAnnually, 1 in 4 people in the UK will experience a mental health problem. Alongside the approach of increasing awareness of the issue amongst the general population, there is a drive to deliver training and education on the recognition and management of mental health crises. Limited resources exist to aid healthcare professionals in delivering mental health first aid (MHFA), with the vast majority focussing on lengthy training courses. Small group problem-based learning (PBL) is utilised widely in medical education and this modality offers advantages in deliverability, audience participation and experiential learning. Our aim was to deliver and explore the effectiveness of a PBL MHFA workshop to various healthcare professionals.MethodAs part of an Emergency Medicine Mental Health Education day, we delivered four 30-minute PBL MHFA workshops. These involved an introduction to MHFA, followed by an interactive discussion of 4 mental health simulated cases, whereby participants anonymously answered a range of questions using the web-based platform Mentimeter. We devised a simple MHFA A,B,C,D,E acronym to bring structure to problem solving. Pre- and post-workshop questionnaires were used to assess outcomes using Likert scales to measure various aspects of MHFA (1 = strongly disagree and 5 = strongly agree). Statistical significance was calculated using T-Test with P &lt; 0.05 defining statistical significance.ResultA total of 28 professionals attended the workshops, 20 (72%) completed both the pre and post workshop questionnaire. 19 (76%) were nurses (5 Registered Mental Health Nurses and 14 Registered General Nurses), 3 (12%) were doctors, 2 (8%) were HCA's and 1 was a policeman. 15 (75%) of the participants reported historically having had the need to deliver MHFA but only 3 (15%) had previously received training. After the workshop, participants reported significantly increased understanding [3.0 to 4.3 (p &lt; 0.05)] and confidence in delivering MHFA [3.05 to 4.30 (p &lt; 0.05)]. There was significantly improved confidence in assessing risk [3.03 to 4.05], calling for appropriate help [3.45 to 4.35] and de-escalation techniques [3.05 to 4.15].ConclusionTo our knowledge this is the first mini PBL-based MHFA workshop. We have demonstrated that the PBL workshop setup is an effective means to deliver training on MHFA. We recognise the importance of MHFA training reaching a larger audience and its potential value if incorporated into national healthcare training programmes and made available to the general public.

Are the rapid tranquilisation nice guidelines adhered to, in patients with agitated/aggressive behavior? a QIP

AimsTo explore whether the NICE guidelines for rapid tranquilisation are adhered to in the Psychiatric intensive care unit (PICU/ Tryweryn).MethodData were collected by core trainees. Standards were taken from NICE guidelines NG10. All patients who had received rapid tranquilisation, that were in PICU from August 2019 to February 2020 were considered in this a.ResultDuring the first PDSA, we discussed with the staff in the ward regarding the protocol. Prior to actually starting the second audit, the adherence was noted to be low. However following persistence and having created a protocol jointly with the ward manager, we could see the difference. The staff were appreciated for their efforts in maintaining 100% adherence. The same was intended to be continued with some positive reinforcement from the auditing team. Over the first 2 months, 12 patients received Rapid Tranquilisation. Out of these 12, we randomly selected 4 patients to find the adherence of the NICE guidelines to be 100 per cent. The predictions regarding the adherence to protocol showed that the PDSA was successful.During the second PDSA, the adherence was 100% again. The adherence to the protocol has been followed for not just the sample that was selected, but for the entire set of patients who received the Rapid Tranquilisation. Following this QIP, we formatted the proforma which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and response to medication.ConclusionThe utilisation of de-escalation techniques and behavioural support plans that was person-centred in turn brought down the rate of Rapid Tranquilisation successfully. Thus placing our PICU as having the least restraints in the UK in 2019 (Second least 3/ month). Our PICU was awarded the prestigious Nursing Times Team of the Year Award for their pioneering work.Following this QIP, we then formatted the proforma for Rapid Tranquilisation which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and patients response to medication. The PICU will continue to maintain this 100% standard and we would then consider extending the Audit to both Open wards and PICU in entire North Wales.

Building Partnerships by Infusing Kindness: A Social Worker and Librarian's Shared Journey to Meaningful Cross-Discipline Collaboration

In this column, the authors will examine an innovative approach to library employee training, as well as reflect on their shared experience through the planning, implementing, and revising process. They will articulate the steps taken in development of a training model that uses a social work simulation lab to provide library employees with the opportunity to practice de-escalation techniques instantaneously with actors demonstrating a spectrum of authentic patron interactions, and experienced professionals, spanning librarianship and social work, providing immediate constructive feedback. To this end, the authors will contribute contemplative best practices for application of techniques relevant across the library discipline, as well as offering evidence of the strategies discussed informing progressive modifications to library-specific safety policies and procedures. The authors will also integrate suggested next steps, including complementary training opportunities based on mental health awareness and self-care.

In-situ child and adolescent mental health simulation with human factors feedback delivered by airline pilots

AimsTo encourage multidisciplinary team learning by introducing Child &amp; Adolescent Mental Health (CAMHS) in-situ simulation training.To provide focused Human Factors feedback through the expertise of senior airline pilots.MethodThe integration of the WingFactors in-situ simulation programme to multiple departments at Whittington Health NHS Trust has transformed the education landscape. The programme has received unanimously positive feedback, and the potential benefits for not only physical, but also mental health training, have been quickly recognised. A total of 90 simulations have been performed. A number of CAMHS scenarios have been designed with the primary aims of encouraging multidisciplinary training and increasing the focus on Human Factors in Psychiatry.Simulation scenarios were performed in real clinical environments with primed actors, thus enabling high-fidelity in-situ simulation. Immediate ‘hot’ debriefs were delivered by clinical faculty and uniformed airline pilots, with emphasis on psychological safety to encourage participation from all team members. The key learning points were then detailed in written documents and circulated to the wider team as a valuable learning resource.The first CAMHS simulation involved the acute management of a collapsed patient in the Emergency Department toilet, with a ligature tied around her neck and accompanied by a distressed patient. Another scenario addressed de-escalation techniques when dealing with a patient presenting with an overdose, who was threatening to leave the ward and posing potential risk to herself.ResultThe nature of these in-situ simulations enabled the multidisciplinary team to analyse practical considerations in the management of acute clinical situations. Scenarios were designed to focus on areas which had been identified as needing improvement for patient safety.The observations provided by airline pilots increased the focus on Human Factors training. A number of key themes were identified, including the importance of effective team-briefing, distraction management and task allocation. This is of particular significance when managing a distressed patient and anxious relative, in a busy high-stress clinical environment.ConclusionIn-situ simulation is a newly emerging concept in the field of Psychiatry, and the success of this programme has been highlighted through consistently positive feedback from participants, and nomination for the HSJ Award (Best Education Programme 2021). The involvement of airline pilots has promoted collaborative learning amongst the multidisciplinary team, and increased the focus on Human Factors in Psychiatry, clearly demonstrating the value of in-situ simulation training in this field.

Agitation and Restraint in a Pediatric Psychiatric Emergency Program: Clinical Characteristics and Diagnostic Correlates.

Agitation and restraint among pediatric psychiatric patients are a frequent, yet little studied, source of morbidity and, rarely, mortality in the emergency department (ED). This study examined agitation and restraint among youth patients in a specialized pediatric psychiatric ED, considering clinical and sociodemographic characteristics of those who required restraint to determine the clinical correlates of agitation and restraint in this population. This descriptive study was a 6-year retrospective chart review of all patients restrained for acute agitation. Demographics, clinical characteristics, diagnoses, and reasons for restraint were collected. Relationships between sociodemographic and clinical variables to types of restraints used were examined, along with change over the study period in rate of and mean time in restraint. The average restraint rate was 1.94%, which remained fairly consistent throughout study period, although average time in restraint decreased significantly. Restraints were more common in males. Adolescents were overrepresented in the ED population, and after controlling for this, restraint rates were similar in adolescents and younger children. Physical aggression was the most frequent precipitant, although among adolescents verbal aggression was also a precipitant (more so than in younger children). Disruptive behavior disorder diagnoses were most frequently associated with restraint. A lower rate of restraint is reported here than has been seen in programs where youths are treated in medical or adult psychiatric EDs. Hospitals without specialized pediatric psychiatric emergency programs should invest in staff training in deescalation techniques and in access to pediatric psychiatric treatment. The finding that, of youth restrained, a significant proportion were under 12 years old and/or carried diagnoses not typically associated with aggressive behavior, indicates that crisis prevention, management, and treatment should include younger populations and diverse diagnostic groups, rather than focusing narrowly on older patients with psychotic or substance use disorders.

Situational Risk Factors for Inmate-on-Staff Assaults

This study examines whether situational characteristics of incidents involving inmates and correctional staff are related to the occurrence of inmate-on-staff assaults. The analyses compare assaultive and non-assaultive incidents at an all-male, maximum security prison. The results of logistic regression models show that several situational characteristics (time, location, behavior of inmates, and actions taken by staff) differentiate between inmate-on-staff assaults and non-assaultive incidents. The results suggest that inmate-on-staff assaults can be reduced through the use of situational crime prevention, as well as training on signs indicating an assault is likely, the effective use of protective strategies, and de-escalation techniques.

Addressing Barriers to HIV Point-of-Care Testing in Community Pharmacies.

Significant numbers of human immunodeficiency virus (HIV) infections are transmitted unknowingly, making efforts to increase HIV testing accessibility crucial. As trusted healthcare providers, pharmacists can increase accessibility of HIV screening and referral services. However, challenges with lack of private counseling and testing space, need for training and education, lack of adequate staffing, heavy workload, and uncertainty supporting patients with reactive results have been previously reported by community pharmacists as barriers to offering HIV screening. The objective of this study was to investigate pharmacists’ opinions of strategies for addressing these barriers. A survey was developed to gather information regarding steps that could be taken to increase pharmacist comfort and interest offering HIV point-of-care testing (POCT) services. Thirty pharmacies were contacted and representatives from twenty-six responded. Pharmacists reported that they were likely or very likely to offer HIV POCT if they were given the following: a 2 h training session on administering and interpreting HIV POCT (73%); a 4 h education session on a variety of HIV education topics (73%); training about couples testing, post-test counseling, and de-escalation techniques (58%); or a semi-annual CE training (58%). Pharmacist respondents were likely or very likely (81%) to implement HIV POCT if there was a protocol in place so that patients with a reactive screening would out be referred for diagnostic testing and if there was a script provided as a template for post-test counseling (81%). The majority of pharmacists (69%) also preferred the appointment-based model rather than a walk-in or combination option and preferred (77%) having 20–30 min of dedicated time with the patient to provide adequate testing, education, and counseling. By using these strategies to improve comfort and likelihood implementing HIV POCT, pharmacists can increase access to HIV testing and decrease the spread of HIV.

The Effectiveness of De-Escalation Techniques as Compared to Physical Restraint/Seclusion on Inpatient Psychiatric Units: A Quantitative Systematic Review

Restraint and seclusion were considered a form of treatment but consistently has led to physical and mental injuries to staff and patients. De-escalation has been viewed as a safer option. Understanding which intervention yields decreased injuries, aggression and violence will guide policy and inform practice. To identify which intervention leads to decreased physical and psychological injury to patients and staff. The frequency of physical injuries to patients and staff from aggressive patients; frequency of psychological injuries to patients and staff from violent, aggressive incidents; frequency of violence, agitation and aggression; competence of staff at managing aggression and violence were evaluated. Fourteen studies were included in this review. There are many forms of de-escalation. Studies where techniques were taught to staff, the intervention was effective in decreasing injury in approximately half the studies. De-escalation techniques taught to patients decreased injury in 100% of the studies included in this review. Consensus on which intervention works best could not be reached, nor is there overwhelming evidence for a particular type of de-escalation better suited for decreasing aggression and violence. Caution should be exercised when choosing a de-escalation technique for implementation in institutions due to lack of regulating agencies that inform practice and standards. In addition, the literature lacks best practices for de-escalation techniques backed by evidence. Restraint and seclusion should be used as a last resort due to inherent risk associated with the intervention.

Decline in Pediatric Emergency Department Behavioral Team Activations After Institution of an Agitation Protocol.

Aggressive behavior among pediatric patients with psychiatric complaints in emergency departments is a growing problem. An agitation protocol was instituted in 1 pediatric emergency department to provide scaled recommendations for differing levels of aggression. The study objective was to determine if the frequency of activation of an emergency behavioral response team changed after protocol initiation. A protocol for escalating management of agitation in pediatric patients was introduced in February 2016. The electronic medical record was queried for subsequent behavioral response team activations over the next 16 months. Patient demographics and specific features surrounding the activation were retrospectively recorded from the medical record, including length of stay, medications administered, and documented deescalation techniques. Frequency and features of behavioral team activations were compared with activations from a period before the planning and implementation of the protocol (May 2014 to May 2015). Twenty-one patient visits were found to require behavioral response team activation over 16 months, compared with 31 for the 13-month preprotocol period. Attempts at verbal/ environmental redirection were seen in 77% and deescalation by medication administration before the activation occurred in 14% of patients. During the behavioral team activation, 81% of the patients were given psychiatric medications and 81% were placed in physical restraints. A decrease from a baseline of 2.4 to 1.3 behavioral response team activations per month, or a 46% decline, was noted following the institution of a clinical protocol for pediatric agitation.

Effectiveness of Video-assisted Teaching on Knowledge and Attitude Regarding De-escalation and Breakaway Technique for Aggressive Behavior among Staff Nurses, at Selected Hospitals, Puducherry

Effectiveness of Video-assisted Teaching on Knowledge and Attitude Regarding De-escalation and Breakaway Technique for Aggressive Behavior among Staff Nurses, at Selected Hospitals, Puducherry

De-escalation Technique Education: The Effect on Student Nurse Perceived Self-Confidence in Coping with Patient Aggression

Workplace violence, in the form of patient-to-nurse assault, occurs in practically all healthcare environments. Patient aggression can increase nurse stress, fear, and create a hostile work environment. Hostile work environments can force nurses to leave the field of nursing prematurely. Implementing de-escalation technique education into the curriculum of junior and senior pre-licensure BSN students is an evidence-based and cost-effective approach to foster a culture of safety. Method: This pre and post-test quasi-experimental designed research project used the Clinician Confidence in Coping with Patient Aggression questionnaire developed by Michael Thackrey (1988) to assess the perceived self-confidence of nursing students before and after receiving de-escalation technique education. Results: There were 59 junior and senior level BSN students who participated in the research project. The majority of the participants were female (n=56, 94.9%), 18-24 years of age (n=34, 57.6%), and in their junior year of the BSN program (n=33, 55.9%). Statistical analysis revealed an increase in perceived self-confidence in coping with patient aggression after completing the de-escalation technique education (p=.000). Conclusion: Educating pre-licensure nursing students how to effectively defuse an escalating patient increases their perceived self-confidence when coping with patient aggression. Providing future nurses with the tools and concepts to create a safer work environment will increase the likelihood of these nurses remaining in the field of nursing until retirement.

Do policy and training changes influence patterns of police use of force? An interrupted time-series analysis

PurposeThe current study examines the effect of changing a specific use-of-force policy coupled with de-escalation training implementation on patterns of police use of force.Design/methodology/approachAn interrupted time-series analysis was used to examine changes in police use-of-force incident records gathered from a large, southwestern US metropolitan police department from 2013 to 2017 based on a TASER policy change and de-escalation training implementation mid-2015.FindingsResults demonstrate that changes to use-of-force policy regarding one type of force (i.e. use of TASERs) coinciding with de-escalation training influence the prevalence of use-of-force incidents by increasing the reported police use-of-force incidents after the changes were implemented. This finding is somewhat consistent with prior literature but not always in the desired direction.Practical implicationsWhen police departments make adjustments to use-of-force policies and/or trainings, unintended consequences may occur. Police administrators should measure policy and training outcomes under an evidence-based policing paradigm prior to making those adjustments.Originality/valueThis study is the first to measure the effects of changing use-of-force policy and implementing de-escalation techniques in training on patterns of police use of force and shows that these changes can have a ripple effect across types of force used by police officers.

“Return of the repressed”: Exposure to police violence increases protest and self-sacrifice intentions for theYellow Vests

Worldwide, it is not uncommon to observe violent police reactions against social movements. These are often rationalized by decision makers as efficient ways to contain violence from protesters. In France for instance, the ongoing Yellow Vests protests have generated an unprecedented number of casualties, injuries, and convictions among protesters. But was this response efficient in diminishing violence stemming from the Yellow Vests? To this day, little is known about the psychological consequences of police violence in the context of protests. Combining insights from Significance Quest Theory and the Social Identity perspective on collective action, we predicted that exposure to police violence could “backfire” and lead to increased radicalization of protesters. A cross-sectional investigation of 523 Yellow Vests yielded evidence for this hypothesis. We found positive direct effects of exposure to police violence on intentions to attend future demonstrations and to self-sacrifice for the Yellow Vests. Moreover, these effects were serially mediated by perceived Loss of Significance and Identification with the Yellow Vests. Paradoxically, these results highlight for the first time the mechanism through which political repression may contribute to the formation of radical politicized identities. Thus, we recommend that decision makers privilege the use of de-escalation techniques in protest policing whenever possible.