Lynn P. Roppolo, MD, remembers years ago when emergency department staff, including doctors and nurses, would be physically assaulted almost weekly.
Roppolo works in the emergency department at Parkland Hospital and Children’s Medical Center and is a professor in the Department of Emergency Medicine at UT Southwestern. Parkland’s ED is one of the busiest EDs in the country with more than 240,000 patient visits annually.
According to Roppolo, a common scenario typically consisted of a patient escalating into a violent rage and several staff and security would have to hold them down to administer calming medications. Restraints and medications were often the first line of defense to control severely agitated and potentially violent behaviors.
Roppolo, first author on the review, “Improving the Management of Acutely Agitated Patients in the Emergency Department Through Implementation of Project BETA (Best Practices in the Evaluation 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 ED patients and has witnessed only one physical assault in the last five years because of it.
In an interview with Nurse.com, Roppolo said her turning point came after reading the series of articles called, “Best Practices in the Evaluation and Treatment of Agitation (BETA),” which were 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 agitation
- Risk assessment, which should dictate the best management strategies
- The antiquated approach of “restrain and medicate” should be the last resort
- How to safely control the behavior of a severely agitated patient if restraint and calming medications are necessary
“De-escalation is a type of conflict resolution or crisis resolution. It is a combination of strategies and techniques used to reduce a patient’s anxiety, agitation, and aggression,” said Tiffany Carder MSN, RN, CEN, Clinical Nurse Educator, Emergency Services at Parkland Health and Hospital System, and an author on the review with Roppolo.
Although different approaches and acronyms exist to guide de-escalation, Roppolo has a commonsense approach that she has used with success.
“De-escalation requires empathy, compassion, kindness, partnering, understanding, and a sincere willingness to help,” Roppolo said. “Try to understand why the patient in front of you is agitated and treat them like you would want to be treated if you were in their shoes.”
Patients are often frightened and paranoid, so one verbal approach is to repeatedly tell them that they are safe and you want to help. Nonverbal communication is just as important as what a nurse says and should relay the same message, according to Roppolo.
The goal is to bring a patient to a state where the staff can safely provide care. However, sometimes the best practices aren’t always in place. Australian suthors of the 2021 paper, “Exploring Staff Experiences: A Case for Redesigning the Response to Aggression and Violence in the Emergency Department,” published in the International Emergency Nursing journal, wrote, “Our 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 predetermined allocation of staff roles for patient restraint.”
The lack of a systematic, coordinated approach for a Code Black — which is the name for the responses of healthcare staff and security personnel to actual or potential verbal and physical aggression or violence by patients, families, or other visitors towards healthcare staff — can lead to confusion.
“When poorly managed, this placed healthcare staff, security personnel, and patients at serious risk and had a negative impact on staff wellbeing,” the authors wrote. ”
Assess the Agitation Level
One of the first steps in de-escalation for nurses and other staff is to assess a patient’s level of agitation. The higher the level of agitation, the greater the risk for violent behavior.
There are scales for measuring agitation levels, including the Behavioral Assessment Rating Scale (BARS), in which a normal-acting person is a 4, mildly agitated is 5, moderately agitated is 6, and severely agitated is 7.
Hospital security needs to be contacted immediately for patients who are severely agitated or escalating to assist with de-escalation or with physical restraint, according to Roppolo.
Risk assessment and de-escalation take place simultaneously. Sometimes de-escalation is relatively easy, according to Roppolo. People might be mildly agitated after waiting in the ED for prolonged periods of time, for example. Simply letting patients talk about what is bothering them and addressing the problem will likely prevent escalation.
In contrast, patients who are in a severely agitated state and are unable to be de-escalated typically require medication to calm their agitated behavior, and physical restraint.
De-Escalation Success Story
Roppolo remembers a case years ago that convinced her that de-escalation is effective.
Nurses requested medications to control an ED patient’s severe agitation. The patient was brought to the hospital by ambulance from a group home and was being restrained by at least five officers when Roppolo walked in the room.
Prior to Project BETA, Roppolo says she would have just ordered medications. Instead, Roppolo decided to attempt de-escalation despite the severity of agitation.
“I walked in the door and looked at him and said, ‘I’m Dr. Roppolo, Sir. I’m here to help you, and you are safe,’” Roppolo explained.
She repeated the words and assured the patient that no one was going to hurt him. She asked everyone in the room to leave, except one officer as a precaution. She sat near the door and far enough away from the patient so that he could not kick, hit, or spit at her.
After five minutes of listening, Roppolo discovered that the patient’s fear and agitation were the result of abuse he was experiencing in his group home. The fact that Roppolo listened brought the man to tears, she said.
Instead of prescribing medications and doing an extensive workup for altered mental status, Roppolo called in the social worker, and within two hours the patient was discharged to a new group home.
“Most people who come in agitated can be de-escalated,” Roppolo said. “Some of them are mentally ill or intoxicated and may require medication … but at least I can bring them down to a level where we can partner with each other. And they often agree to take the medication orally, if we give it with a sandwich or something to drink.”
There are signs that nurses can look for that suggest a patient or a patient’s family and friends might become easily angered or agitated, according to Carder.
“Researchers have recognized several behavioral cues that may be associated with potential violence,” she said. “One good tool to use is the STAMP violence assessment tool. The STAMP acronym stands for Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, and Pacing. The emergency department at Parkland Memorial Hospital, where I work, uses this screening tool on every patient during triage. The screen is positive if one of the behaviors is observed.”
The 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 are also provided with badge buddies that have the STAMP tool and de-escalation techniques on it,” Carder said.
According to Carder, specific de-escalation strategies that nurses can practice are:
- Stay two arms’ length away.
- Maintain a relaxed posture and look.
- Speak with a calm voice with visible hands.
- Acknowledge what the patient is saying.
- Do not threaten.
- Set boundaries.
- Do not use medical jargon.
- Be non-judgmental.
- Show empathy.
- Use this patient’s name.
- Be OK with silence.
- Do not argue.
- Define consequences of behavior.
- Be respectful.
- Do not answer inappropriate questions.
- Treat with dignity.
- Use Trauma-Informed Care, and take the whole person into account: past experiences and current experiences.
Take these courses on related topics:
Trauma-Informed Care: The Impact of Adverse Childhood Experiences (ACEs) on Health
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Adverse childhood experiences (ACEs) have lasting negative effects on adult health, in the form of risk-taking behaviors, and chronic disease. Healthcare professionals have a unique opportunity to address these risk factors with screening, acknowledgement, and referrals for treatment. This continuing education program reviews the research and science of how childhood trauma affects adult health and wellness, explains how to screen for risk factors, and describes how to promote healing and resilience with trauma-informed care.
Restraints: Reducing Risks to Patients and Alternatives
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The purpose of this course is to inform nurses about the potential dangers of restraints and ways to reduce their use. The course includes an overview of regulations and standards of care for the use of restraints but emphasizes alternatives.
Preventing Violence in the Healthcare Setting
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Violence in healthcare settings reflects the chaos of a broader work environment. Experts not only agree on the extent of violence in the healthcare setting, but also concur on its best treatment: education and prevention. Nurses heighten their awareness and expertise in dealing with violence in their professional settings by learning to identify risk factors and warning signs, and by applying interventions that can shield their patients and themselves from harm.