Embed Size (px)
Citation preview
Agitated PatientSteps To Take To Stay Safe
Objectives: You will be able to :1. Define the problem-agitation vs violent
2. Assess agitated patient and determine best approach
3. Apply de-escalation methods
4. Learn methods to address after effect exposure to staff
About Peoples Community Health Clinic
Peoples Community Health Clinic, Inc. is a nonprofit health care clinic known for providing high quality, comprehensive care to all people in the Cedar Valley, no matter their financial situation. Both uninsured and insured patients are welcome. Guided by its mission statement, Peoples Clinic is dedicated to providing access to affordable, compassionate, high quality health care to all at both its main clinic in the heart of downtown Waterloo and satellite clinic in Clarksville. Primary care, dental services, behavioral health counseling and urgent care are just a few of the Clinic’s many offerings in addition to on-site laboratory, x-ray and pharmacy.
Our Services & Providers
Comprehensive Health Care
• Medical Care
• Dental Care
• Urgent Care
• Counseling - Family Concerns,
Substance Abuse Problems,
Nutritional Concerns, and
Homelessness
• Laboratory
• Pharmacy
• X-Ray
Additional Support
• Benefit Counseling to Determine Financial
Eligibility for Health Care Services
• Care for Children with Special Health Care
Needs
• Chronic Care Management
• Health Care for the Homeless Program
• Health Education and Community Health
Promotion Programs
• Interpreters On-Site: Bosnian, Spanish,
Burmese and French
• Pediatrician Hospital Visits
• Reach Out and Read Pediatric Literacy
Program
Medical & Dental Providers
Physicians
• 4 Family Practice Physicians
• 2 Internal Medicine Physicians
• 6 Pediatricians
Mid-Levels
• 9 Nurse Practitioners
• 1 Physician Assistant
Dentists
• 3 General Dentists
• Dental Hygienists
• 3 Dental Hygienists
Epidemiology
• Between 2011-13 workplace assaults ranged from 23,540 to 25,630 annually, with 70-74% occurring in health care and social service settings.
• Up to 50% of healthcare providers are victims of violence sometime during their careers.
How would you respond?
• Patient is in exam room, not interested in answering any questions and begins pacing…..
• Patient comes to the window demanding to see/talk to provider, starts to raise voice……
• Provider seeing patient, patient starts clenching fists, flushing in face, staring directly at provider ………..
What steps would you take?
Agitated vs Violence
• Agitated: feeling or appearing troubled or nervous
• Violence: behavior involving physical force intended to hurt, damage or kill someone or something.
• Violence in a clinical setting may be seen as a severe expression of agitation
Assessing the Patient
Some patients just seem to have a knack for making us feel uncomfortable. Some reasons are obvious, others we can’t put a finger on.
There is a big difference between a patient who is surly and one who is scary.
• Surly patient can be intimidating, quick-tempered, argumentative and demanding
• Scary patient can take you from being confident to cowering in a heartbeat, body language, facial expressions and use of certain words.
Assessing the Patient continued
It is important to take a step back, literally and figuratively. Doing so will help give you a moment to evaluate the cause of their conduct, understand where the patient is coming from and how you can help them. This also gives you a moment to understand why you are feeling apprehensive.
A patient can go from calm to irritable to pacing to lashing out to clenched fists, flushed face to outright violence in a heartbeat. De-escalation interventions at an early stage is important.
Causes of Patient Agitation
Metabolic/physiologic Mental/behavioral Health Substance use Iatrogenic
Hypoglycemia Dementia Alcohol Postop anesthesia
Head injury/cerebral
(stroke, seizure)
Developmental disabilities
Sundowning
Narcotics
Infection, sepsis Psychosis Stimulants Sedation
Hypoxia, hypercarbia Parasomnias Steroids/testosteroneWithdrawal symptoms
Organ failure (renal/liver)PTSD Synthetic drugs Drug-drug interactions
Hypo or Hyperthermia Personality disorders Hallucinogens Long wait times
PainToxins Perception of unfair
treatment
Level of Agitation
• Various scales can help determine the level of agitation in a patient. The following scale is Agitated Behavior Scale (ABS) and is used by clinic sites as well as Emergency Departments.
Agitated Behavior Scale (ABC)
As soon as signs of agitation are evident, this approach can be used to help determine a broad level of risk for violence on the part of the patient.
ABC approach entails:
A - Assessment of the medical history, current status, patient appearance, orientation and symptoms of escalation (flushed skin, dilated pupils, shallow rapid respirations and perspiring)
B – Behavioral indications (yelling, use of obscenities, clenched fists, damaged property, extremely irritable or hostile behavior)
C – Conversation (patients self-reporting the intent to harm him or herself or others, the availability of weapons, hallucinations, substance abuse, etc.)
(Corrigan, JD 1989)
General Prevention Measures
• Security Personnel
• Alarm systems: panic buttons in all rooms
• Limiting access: coded doors
• Staff Education: brief, regular educational sessions and debriefing after an incident
Patient De-escalation Techniques
• Based off of the American Association for Emergency Psychiatry Project Beta
10 Domains:
1. Respect personal space: Be at least 2 arms length way from patient. If patient states, “Get out of my way” let the patient leave. If possible patient and provider should be equidistant to the door.
Patient De-escalation Techniques
2. Do not be provocative: Keep calm. Demonstrate by body language that one wants to help. (Hands visible and not crossed, stand at an angle to patient as not to appear confrontational, no prolonged eye contact) Have a calm demeanor and facial expression and show compassion.
3. Establish verbal contact: only 1 person verbally interacts with patient. Usually the first person to make contact but if not trained then the first trained provider. Introduce yourself and provide orientation and reassurance
Patient De-escalation Techniques
4. Be concise: Keep it simple. Use short sentences and simple vocabulary. Give patient time to process information. Repetition is essential to success. Repeat message(setting limits, offering choices or proposed alternatives) until its heard.
5. Identify wants and feelings: Does patient want to ventilate to empathetic listener, want a medication or administrative intervention such as work note, disability papers filled out. Does patient want help talking to significant other? Acknowledge feelings and frustrations. Listen to patient and watch body language.
Patient De-escalation Techniques
6. Listen closely to what patient is saying. Repeat back what patient is saying. “Tell me if I have this right”
7. Agree or Agree to disagree: 3 ways to agree with patient:
a. Agreeing with the truth (Yes she stuck you 3 times, Do you mind if I try?)
b. Agreeing in principle. If patient feels disrespected “I believe everyone should be treated respectfully.”
c. Agree with the odds. If patient complains of wait time then can acknowledge that “there are probably other people who would be upset also.”
Patient De-escalation Techniques
8. Lay down the law and set clear limits: Clearly inform patient about acceptable/unacceptable behaviors. Communicate matter of fact and nonthreatening. Limit setting must be reasonable and done in a respectable manner. Being treated with respect and dignity must go both ways. Let patient know you are there to help him regain control and establish acceptable behavior. Long term coach the patient in how to stay in control. ( take deep breath, talk calmly, walk away, count to 10, etc.)
Patient De-escalation Techniques
9. Offer choices and optimism: Patient as 3 choices (calm down, fight or take flight). Choice is the only source of empowerment when one believes physical violence is a necessary response. Also offer things that will be perceived as an act of kindness ( chair, glass of water, phone)
10. Debrief staff and patient: Teach patient how to express himself appropriately or how to request a time out. Debrief staff after each incident. Offer counseling if needed.
Review: Main principles of patient de-escalation
Remain calmAvoid aggressive postures and prolonged eye contact
Use soft, calm, and clear voice
Use simple language without being condescending
Show compassion
Be nonconfrontationalListen to the patient; treat him/her respectfully
Avoid giving opinions on issues beyond your control
Acknowledge the patient’s frustration/perceptions
Ask open ended questions
Offer comfortable area/neutral zone
Avoid excessive stimulation
Review: Main principles of patient de-escalation
Assess available resources, including
• Clinical team members
• Family members, caretakers
• Security guards, police officers in the vicinity
• Call bell, silent alarms
Review: Main principles of patient de-escalation
Manage the situation and the patient’s underlying issues/diagnoses1. Mobilize other patients to avoid collateral damage
2. Ensure agitated patient is not positioned between you and the exit-quick escape for you
3. Explore solutions with the patient
4. Do not try and stop the patient when storming out of the room/building
5. Consider both acute and long-term management
6. Take another staff member into the room if you are feeling uncomfortable
7. Consider pharmacologic, as well as nonpharmacologic approaches (physical restraints last resort)
8. Refer patient to appropriate services/providers as necessary
De-escalation Tips for Staff
• Ensure that agitated patient is not positioned between you and the exit so you can quickly escape if necessary.
• Do not try and stop patient when storming out of room
• Get help immediately when you sense a change in patient behavior.
• Take another staff member into the room if you are feeling uncomfortable.
• Show concern rather than a show of force can strengthen the perception that interventions are coming from a place of caring.
Process at Peoples Community Health Clinic
Situations:
• Pediatric suicidal patient
• Adult patient yelling, cursing, refusing to leave
• Dismissed patient from practice without trying to help, due to staff fear
• Active Shooter Drill
• Violence outside clinic – injured patient comes into clinic for treatment
Treatment for Staff Following Traumatic Situation
Treatment For Staff
Examples Immediate medical care
***CISD Trauma-focused **CBT Pharmaco-therapy
Physical Bodily injury, injury to personal property such as clothes or glasses X X X
Psychological Symptoms or diagnosis of ****PTSD, *ASD, depression, anxiety X X X
Emotional Anger, fear, frustration, shock, sadness X X
Work Functioning Permanent disability/sick leave, move to new work location, change in hours or practices, leave profession
X
Patient Care Fear of all patients, decreased quality of care, less enjoyment in caring for patients, less interest in patients, less time spent with patients
X
Social Increased concern about violence in community X
*ASD-acute stress disorder **CBT-cognitive behavioral therapy; ***CISD-critical incident stress debriefing ****PTSD-posttraumatic stress disorder
References
1. West J Emerg Med. 2012 Feb, 13 (1): 17-25 Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry, Project BETA
2. Journal of Family Practice, March, 2018 vol 67 (3): 136-146. The Agitated Patient: Steps to take, how to stay safe
3. UptoDate. 2017 Oct. Assessment and emergency management of the acutely agitated or violent adult
4. Journal of Clin Exp Neuropsychol. 1989, March;11(2):261-277, Development of a scale for assessment of agitation following traumatic brain injury
Questions? Thoughts?
Comments?
Sharon Duclos, MD
Co-Medical DirectorPeoples Community Health Clinic
905 Franklin St.Waterloo, IA 50703
Lanett Kane, RN BSNDirector of Quality
Peoples Community Health Clinic905 Franklin St.Waterloo, IA 50703319-874-3487
