PRACTICE PARTNER
Empower patients too, by encouraging
them as they work to calm themselves. And
if what you’re doing isn’t working, see if a
colleague might have more success before you
turn to other options.
Studying data around incidents can also
lead to solutions. At St. Joseph’s Healthcare in
Hamilton, the Schizophrenia and Commu-
nity Integration Service noted an increased
risk of responsive behaviours at breakfast.
They interviewed staff, looked at patterns
and found many early warning signs in the
12 hours prior, during the night shift. So
the team worked to de-escalate responsive
behaviour before it turned into a violent in-
cident. They also moved team safety huddles
to before breakfast for the most
at-risk units, and increased staff
presence at breakfast. Incidents
have since gone down.
Doctors and
When responsive behaviours
other health-care are happening, always try to get
at the root causes, says Dr. David
professionals
Conn, VP of Education and a
should never be
staff psychiatrist at Baycrest in
surprised by or
Toronto. He notes that a lot can
be at play, like physical reasons
unprepared for
(e.g., the condition or pain),
such situations
changes in cognition, emotional
reactions, the environment (is
it noisy or crowded?), etc. For
doctors, patient-centred care and
level-headedness should prevail.
“If we get upset, they’ll get more upset,”
says Dr. Conn.
Dr. Peter Prendergast, CPSO Medical
Advisor and a psychiatrist, says restraints,
both physical and chemical should be the last
resort. They’re especially dangerous for the
frail elderly. Skilled non-confrontational com-
munication, he says, is the key to lowering
the temperature.
Baycrest is working on an app that will
give staff instant information on patients
(mostly those with dementia), such as their
background, family, likes and dislikes, etc. It
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DIALOGUE ISSUE 4, 2018
will encourage staff during tense moments
to see patients as people, not as a situation to
handle. And knowing more about them, says
Dr. Conn, just might help people keep their
own tone or attitude respectful.
In implementing de-escalation techniques,
think too of logistics, says Dr. Prendergast.
He says that when a coronary event happens
at a hospital, everyone knows what role to
play. Yet when a patient or visitor has a vio-
lent outburst in a hospital, there’s confusion
as to who does what. It can create chaos and
uncertainty.
That shouldn’t happen, he says. Staff should
have an understanding as to who will take the
lead role in calming and relationship-building
with the patient, who will clear the room of
other patients, and who will ensure that chairs
and other potential weapons in the room are
not at hand.
A training program organized by the
facility and taken by employees will foster
a team approach that ensures everyone is
working from the same script. Responding
on the fly makes things more dangerous
for everyone, including the patient, other
patients and staff.
Dr. Prendergast says that it’s not necessarily
the doctor who has to take the lead. In fact,
if a doctor happens onto the scene and tries
to take the lead, but hasn’t been trained in
de-escalation, he or she could undo the work
of whomever may have been having some
success in calming the agitated patient.
Some doctors are better than others at
de-escalation. When de-escalation programs
started, nurses (being the most vulnerable to
assault) were the ones who pushed for change.
Dr. Prendergast suggests that all doctors
should take de-escalation training, because
you never know which patient will become
aggressive or violent.
Doctors and other health-care professionals
should never be surprised by or unprepared
for such situations – and that means having
strategies to defuse them.
MD