De-escalation

De-Escalation Strategiesfor Dealing

with the Agitated Patient

Joachim Unger, MDGermany

Aggressive behavior against health care providors

Why ?

Aggression in Prehospital Care/ ED

Acute Pain Intoxication Limited informations Waiting time

Kinds of Aggression

Instrumental-premeditated-

controlled-planned-proactive-cold blooded-hidden-

predatory-postitve/constructive

Emotional-hostile-impulsive-

uncontrolled-unplanned-reactive-

hotblooded-overt-affective-negative/

destructive

Aggression in Health Care: Escalated Interaction

Escalation

Conflict

Anger/Fear

AdversiveStimulationEmpathy/

Theory of Mind

Violence

Social System

Interaction

Mental System

ExpectationRole

NOW-modell

Elements of violente situations

trigger – weapons – target – level of arousal

Key Components

MANAGEMENT

YourselfMaintaining

personal control

situational awareness strategies for de-escalation

(when/where/how)

Communications Verbal and non-verbal

skills

Structure(environment)

safe conditions

Basic Strategies

EmpathyEarly Intervention

Only one communicatorAssessment of emotional state

Characteristics

of effective De-escalators

Open - Coherent - Confident Concern for the patient

Maintaining Personal Control

Appearing calmAvoiding personal feelingsSupressing feelings of anger

.

Identifying theEscalated Patient

High piched voice

Excessive

Sweating

Shaking

Non-VerbalDe-Escalation

Keep an alert postureNeutral facial

expression

Never turn your back for any reason

Limit eye contact

VerbalDe-

Escalation

Do not get loud

Be honest

Be respectful

Respond selectively

Strategies

Find out the reason

Give guidance

Autonomy confirming vs.Authorative

Interventions

Establish rapportAssessment of emotional state

Autonomy confirming

Interventions

Find aggreementsList consequences

Suggest alternativesEmpathize with feelings

Do not try to argue/ convince

De-Escalating Aggressive Behaviour 1. Valuing the patient

2. Reducing fear 3. Enquiring about patient’s queries and anxiety 4. Providing guidance to the patient 4. Working out possible agreements 6. Remaining calm 7. Crosscheck: Take no risk

…brings the level of arousal down to a safer place

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