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De-escalation

Situation
A hostile or physical situation from an individual client, between clients, staff and clients or any combination of the situations mentioned, can immediately affect the safety to all individuals involved in or around the situation, and it can create a potentially dangerous crisis.  The greatest responsibility in human services is to protect the safety and well-being of all individuals. De-escalation should be used first and foremost.   Written policy detailing explicit criteria must exist to which and when these methods should be utilized in crisis situations.

Numbers Nationwide
“In October 1998, The Hartford Courant published a five-part investigative series that revealed an alarming number of deaths resulting from the inappropriate use of physical restraints in psychiatric treatment facilities across the United States. A 50-state survey conducted by the newspaper documented at least 142 deaths in the past decade connected to the use of physical restraints or to the practice of seclusion. The report also suggested that the actual number of deaths is many times higher because many incidents go unreported. According to a separate statistical estimate commissioned by The Courant and conducted by the Harvard Center for Risk Analysis, between 50 and 150 restraint- or seclusion-related deaths occur every year across the country.

To Restrain or To Not Restrain
The Joint Commission's Board of Commissioners report indicates that the organizations that experienced the restraint deaths identified the following areas of root causes:

• Patient assessment, such as incomplete medical assessment or incomplete examination of the individual (for example, failure to identify contraband, such as matches).
• Inadequate care planning, such as alternatives not fully considered, restraints used as punishment, and inappropriate room or unit assignment.
• Lack of patient observation procedures or practices.
• Staff-related factors, such as insufficient orientation or training, competency review or credentialing, or insufficient staffing levels.
• Equipment-related factors, such as use of split side rails without side rail protectors; use of two - point rather than four-point restraints; use of a high-neck vest; incorrect application of a restraining device; or a monitor or an alarm not working or not being used when appropriate.

Policies and Procedures
Well written policies and procedures within your program should clearly define activities and protocol from admission, involuntary admission, assessments, client transfer, therapeutic intervention for acting out individuals, and de-escalation methods along with monitoring responsibilities and care giving duties.   

All staff members should be trained to recognize and respond appropriately to the “eight stages of escalation”:

Eight Stages of Escalation:

De-escalation Tips:

1. Always identify yourself to the patient/client.
2. Speak and think calm.
3. Ask the patient/client how they are doing, if they are hurt and what is going on.
4. Assess for medical problems.
5. Ask the patient/client if they are having difficulty or what happened before they got upset.
6. Remember why the patient/client is in the hospital/residence.
7. Find a staff member that has a good rapport. Have that person talk to the patient/client, and let the patient/client know you are there to listen.
8. Offer medication if appropriate or necessary.
9. If a patient/client screams or swears, reply with a calm nod, don’t react.
10. Help patient/client remember and use coping mechanisms they have identified in therapy.
11. Use team or third party approach if patient/client is wearing down one staff member.  Have someone else step in (10 minutes of talking may avoid restraints).
12. Reassure patient/client and maintain professional boundaries (express your concern for their safety and that you are there to help).
13. Allow quiet time for patient/client to respond, silent pauses are important.
14. Ask the patient/client if they would be willing to talk to you (repeat requests persistently and kindly).
15. Respect needs to communicate in different ways (language/cultural differences) as well as fear, embarrassment, or shame that they may be experiencing.
16. Empower the patient/client and encourage them in every step towards calming themselves that they take.
17. Talk over the upsetting situation even though it may be difficult and painful.
18. Acknowledge the significance of the situation for the patient/client.
19. Ask the patient/client how else you can help.
20. Ask the patient/client for permission to share important conversation with other caretakers for ongoing discussion.

“When there is a need to utilize seclusion or restraints, facilities will treat patients with the utmost dignity and respect and protect them from humiliation. Facilities must have written policies that include last resort indications for the use of seclusion or restraints, and specific monitoring parameters during the period of seclusion or restraint, such as the frequent monitoring of neurological condition, vital signs and placement of restraint.”

De-escalation Technical Bulletin

Please click on the link for additional information on de-escalation, seclusion, restraints, and behavior management:
* De-Escalation

Crisis De-escalation Management Resources

The Mandt System‚
David Mandt & Associates
PO Box 831790
Richardson, TX 75083-1790
Phone - 972-495-0755  Fax - 972-530-2292
http://www.mandtsystem.com/

Nonviolent Crisis Intervention
Crisis Prevention Institute, Inc. (CPI)
3315-K North 1245h Street,
Brookfield, WI 53005  Phone - 800-558-8976
http://www.crisisprevention.com
Professional Assault Response Training (PART)
6105 Glenhurse Way
Citrus Heights, CA 95621-1720
Phone - 916-723-3802

Therapeutic Crisis Intervention (TCI)
Residential Child Care Project
Family Life Development Center -College of Human Ecology
Cornell University, Ithaca, NY 14853
Phone 607-254-5210; fax 607-255-4837

Therapeutic Options, Inc.
100 Delaplane Avenue
Newark, Delaware 19711
Phone - 302- 753-7115
http://www.therops.com/

Additional Resources
Magellan Position Statement on the Use of Seclusion and Restraints

Sentinel Event Alert, “Preventing Restraint Deaths,” Joint Commission on Accreditation of Healthcare Organizations, Issue Eight; November 18, 1998. 

http://www.naphs.org/rscampaign/index.html

Crisis Alleviations Lessons and Methods (CALM)
Telephone (573) 445-3823

For additional value-added safety information, please log on to our loss control website and register at: http://www.losscontrol.com

Contact Information

HOME OFFICE CONTACTS

Mark Konchan, ARM CSP
Vice President
Home Office – Bala Cynwyd, PA
Phone: (800) 873-4552 ext. 2967
E-Mail: mkonchan@phlyins.com

Bill Mesure, Sr. Loss Control Consultant
(Mid-Atlantic Region)
Home Office – Bala Cynwyd, PA
Phone: (800) 873-4552 ext. 5876
E-Mail: bmesure@phlyins.com

REGIONAL OFFICE CONTACTS

Leslie Dugan, Assistant Vice President
(Sunbelt, Western, Northwest,
Rocky Mountain Regions)
Mission Viejo, CA
Phone: (800) 994-4121 ext. 236
E-Mail: ldugan@phlyins.com

Thomas Merritt, Loss Control Consultant
(Sunbelt, Western, Northwest Regions)
Mission Viejo, CA
Phone: (800) 994-4121 ext. 223
E-Mail: tmerritt@phlyins.com

Kenneth R Zimmerman, CSP
Regional Loss Control Manager
(Rocky Mountain)
Littleton, CO 80127
Phone: (866) 608.5898 ext. 5351
E-Mail: kzimmerman@phlyins.com

Brett Hines, Regional Loss Control Manager
(Central, Southwest Regions)
Independence, MO
Phone: (877) 439-7459 ext. 3267
E-Mail: bhines@phlyins.com

Ron Quattrochi, Regional Loss Control Manager
(Northeast Region)
Stoughton, MA
Phone: (888) 292-3881 ext. 268
E-Mail: rquattrochi@phlyins.com

Scott Holt, Sr. Loss Control Consultant
(Metro Region)
Lawrenceville, NJ
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George Kalule, Loss Control Consultant
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Naperville, IL
Phone: (800) 547-9967 ext. 2256
E-Mail: gkalule@phlyins.com
 
Philip Azar, Sr. Loss Control Consultant
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Kennesaw, GA
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IMPORTANT NOTICE - The information and suggestions presented by Philadelphia Indemnity Insurance Company in this E-Brochure is for your consideration in your loss prevention efforts. They are not intended to be complete or definitive in identifying all hazards associated with your business, preventing workplace accidents, or complying with any safety related, or other, laws or regulations. You are encouraged to alter them to fit the specific hazards of your business and to have your legal counsel review all of your plans and company policies.