Crisis Definition- All patients and visitors are in some type of perceived crisis when seeking medical attention.
Pre-Escalation Goal is to manipulate the environment to make it as inviting as possible and eliminate potential triggers
Strategy Staff need to identify an early pre-escalation strategy. Strategy can be introduced at earliest warning sign or even suggested on initial assessment Strategy is a calming mechanism to manage and minimize stress and to prevent a perceived crisis from escalating
Examples of Strategy Stress balls in a basket Coloring activities Stretching Deep breathing Music Reading materials Massage chair Rubber band on wrist Prayer books Run hands under cold or warm water Blankets Note cards Aromatherapy Games Progressive muscle relaxation Snacks on hand
Triggers A trigger is something that sets off a reaction. It could be anything that the patient associates with negative thoughts or feelings. Examples include: Loud voice Excessive hand motions People too close or attempting to touch Bedtime Men Not being listened to Lack of privacy Room checks
Early Warning Signs Early warning signs may be difficult to assess in a high stress/traffic area. Initial assessment is a key so a change from baseline behavior is recognized. - Restlessness - Agitation - Pacing - Shortness of breath - Sensing a tightness in the chest - Sweating - Becoming mute and dissociative
Examples of Early Warning Signs Restlessness Agitation Pacing Shortness of breath Sensing a tightness in the chest Sweating Becoming mute and dissociative Breathing hard Rocking Clenching teeth Wringing hands Bouncing legs Shaking Crying Giggling Heart pounding Singing Excessive eating Swearing
De-Escalation Person is already in crisis mode and starting to escalate. In phase one or two of crisis cycle Recognize possible transference and counter- transference interactions
De-Escalation Strategies Does initial Nursing assessment include a de- escalation assessment? Is it possible to designate an area to address sensory needs? If not, what about a comfort box? 75% reduction in restraints/seclusion over 2 year period after introduction of sensory sessions in a MA hospital
What Makes you Feel Upset? Circle all that make you feel sad, mad, scared or other Being touched Crowds Dark/night Time of day Time of year Yelling/shouting Storms Loud noises
How do I know I am Angry, Scared or Upset? Cry Clench Teeth Loud Voice Flush, hot face Rocking/withdraw/ preoccupy Pace/hyper Heart Pounding Clench fists Breath hard
HALT Easy acronym to employ in your training: H- Hungry? A- Angry? L- Lonely? T- Tired? Thirsty?
Joint Commission and CMS Standards Comparing Joint Commission Restraint Standards and CMS Standards document Comparing Joint Commission Restraint Standards and CMS Standards document Common themes between hospital not deemed, deemed, behavioral health, and CMS guidelines. - Philosophy and definition - Appropriate staffing - Physician/LIP order - Monitoring and assessing the patient - Documentation - Staff training
Definition of Restraint Restraint= Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets or other methods that involve the physical holding of a patient for the purpose of conducting routine physical exam or tests, or to protect the patient from falling out of bed or to permit the patient to participate in activities w/out the risk of physical harm (this does not include a physical escort)
Definition of Seclusion Seclusion= the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self- destructive behavior.
Philosophy Vs. Practice Organization must develop a philosophy related to the use of seclusion and restraint Must ensure that practice supports philosophy
Other things to Include Trauma Informed Care Debriefing
Hands on Approach with a combative person Holds Take Down Lift Carry