De-escalation techniques to help keep staff and patients safe

Lynn P. Roppolo, MD, recalls that years ago emergency department personnel, including doctors and nurses, were 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 ER is one of the busiest ERs in the country with over 240,000 patient visits per year.

According to Roppolo, a common scenario usually involved a patient escalating into a violent rage and multiple staff and security having to restrain them to administer calming medication. Restraints and medication were often the first line of defense in controlling highly agitated and potentially violent behavior.

Roppolo, first author of 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 it had completely changed its approach to agitated ER patients and had only witnessed one physical assault in the past five years because of it.

In an interview with, Roppolo said his turning point came after reading the series of articles called “Best Practices in the Evaluation and Treatment of Agitation (BETA)”, which were written by medical experts from around the world. emergency 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 “control and cure” approach should be the last resort
  • How to safely control the behavior of a very agitated patient if restraints and painkillers are needed

“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, Health Services. emergency at Parkland Health and Hospital System, and author of the review with Roppolo.

Although different approaches and acronyms exist to guide de-escalation, Roppolo has a common-sense approach that she has used with success.

“De-escalation requires empathy, compassion, kindness, partnership, understanding and a sincere willingness to help,” Roppolo said. “Try to understand why the patient in front of you is agitated and treat him as you would want to be treated if you were him.”

Patients are often frightened and paranoid, so a verbal approach is to tell them repeatedly that they are safe and that you want to help them. Nonverbal communication is just as important as what a nurse says and should convey the same message, according to Roppolo.

The goal is to bring a patient to a state where staff can safely provide care. However, sometimes best practices are not always in place. The Australian authors of the 2021 paper, ‘Exploring Staff Experiences: A Case for Redesigning the Response to Aggression and Violence in the Emergency Department’, published in the journal International Emergency Nursing, wrote: ‘Our findings show that there is no There are no guidelines for: assessing the risk of an agitated patient, best practices for de-escalation, exactly when to call a code black, and predetermined assignment of staff roles for patient restraint.

The absence of a systematic and coordinated approach to a code black – which is the name for healthcare staff and security staff responses to actual or potential verbal and physical assault or abuse by patients, families or other visitors to healthcare staff – can lead to confusion.

“When mishandled, it put healthcare staff, security staff and patients at risk and negatively impacted staff well-being,” the authors wrote. ”

Assess the level of agitation

One of the first steps in de-escalation for nurses and other staff is to assess the patient’s level of agitation. The higher the level of agitation, the greater the risk of violent behavior.

There are scales to measure levels of agitation, including the Behavior Rating Scale (BARS), in which a person acting normally is 4, mildly agitated 5, moderately agitated 6, and severely agitated 7 .

Hospital security should be contacted immediately for patients who are severely agitated or worsening to help with de-escalation or physical restraint, according to Roppolo.

Risk assessment and de-escalation take place simultaneously. Sometimes de-escalation is relatively easy, according to Roppolo. People may be slightly agitated after waiting in the emergency room for long periods of time, for example. Simply letting patients talk about what’s bothering them and sorting it out will likely prevent escalation.

In contrast, patients who are in a state of severe agitation and cannot be defused usually require medication to calm their agitated behavior and physical restraint.

De-escalation success story

Roppolo recalls a case years ago that convinced her that de-escalation works.

Nurses ordered medication to control a patient’s severe agitation in the emergency room. The patient was brought to the hospital by ambulance from a group home and was restrained by at least five officers when Roppolo entered the room.

Prior to Project BETA, Roppolo says she would have simply ordered drugs. Instead, Roppolo decided to attempt a de-escalation despite the severity of the unrest.

“I walked in the door and looked at him and said, ‘I’m Dr Roppolo, sir. I am 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 for one officer as a precaution. She sat near the door and far enough from the patient that he couldn’t kick, kick or spit on her.

After five minutes of listening, Roppolo discovered that the patient’s fear and turmoil resulted from the abuse he was experiencing in his group home. The fact that Roppolo listened brought the man to tears, she said.

Instead of prescribing medication and doing a thorough workup for an altered mental state, Roppolo called the social worker, and within two hours the patient was discharged to a new group home.

“Most people who arrive agitated can be defused,” Roppolo said. “Some of them are mentally ill or intoxicated and may need medication… but at least I can bring them down to a level where we can relate to each other. And they often agree to take the medicine by mouth, if given with a sandwich or something to drink.

De-escalation tips

According to Carder, there are signs nurses can look for that suggest a patient or a patient’s family and friends could easily become angry or agitated.

“Researchers have recognized several behavioral cues that may be associated with potential violence,” she said. “A good tool to use is the STAMP violence assessment tool. The acronym STAMP 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 for every patient during triage. Screening is positive if any of the behaviors are observed.

Parkland Health and Hospital System nurses are trained in de-escalation using Satori Alternatives for Managing Aggression, which teaches verbal and physical de-escalation strategies, as well as self-defense techniques.

“Nurses also get badge buddies that have the STAMP tool and de-escalation techniques on them,” Carder said.

According to Carder, specific de-escalation strategies that nurses can practice are:

  • Stay two arm’s length away.
  • Maintain a relaxed posture and appearance.
  • Speak in a calm voice with visible hands.
  • Acknowledge what the patient is saying.
  • Don’t threaten.
  • Set limits.
  • Do not use medical jargon.
  • Be non-judgmental.
  • Show empathy.
  • Use the name of this patient.
  • Accept the silence.
  • Do not discuss.
  • Define the consequences of the behavior.
  • Be respectful.
  • Do not answer inappropriate questions.
  • Treat with dignity.
  • Use trauma-informed care and consider the whole person: past experiences and current experiences.

Take these courses on related topics:

Trauma-Informed Care: The Impact of Adverse Childhood Experiences (ACE) on Health
(1 hour contact)
Adverse childhood experiences (ACE) have lasting negative effects on adult health, in the form of risky behaviors and chronic diseases. Healthcare professionals have a unique opportunity to address these risk factors through screening, recognition and referral to treatment. This continuing education program examines the research and science on how childhood trauma affects adult health and well-being, explains how to screen for risk factors, and describes how to promote healing and resilience with trauma-informed care.

Constraints: reduction of risks for patients and alternatives
(1 hour contact)
The purpose of this course is to educate 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.

Prevention of violence in the healthcare environment
(1 hour contact)

Violence in healthcare settings reflects the chaos of a wider work environment. Experts not only agree on the extent of violence in healthcare settings, but also agree on its best treatment: education and prevention. Nurses build their awareness and expertise to deal with violence in their workplace by learning to identify risk factors and warning signs, and applying interventions that can protect themselves and their patients from harm .


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