Talk Down: Joint Commission on De-escalation

This member-only article appears in the April issue of Patient Safety Monitor Journal.

At 10 p.m. on May 20, 2018, a patient was transported by the fire department to Loretto Hospital in Chicago and put into a wheelchair in the emergency department. It was a Friday night, and the patient had been brought in for alcohol abuse.

About an hour later, the patient and a patient care technician (PCT) got into a heated verbal altercation. The patient then got up from his wheelchair and walked toward the PCT. Another staffer tried to stand between the two, but the PCT pushed the patient “very hard.” The patient fell and hit his head on the front of his hospital bed, “causing a deep laceration to the head.”

CMS later cited the facility for violating the patient’s right to be free from abuse and harassment.

This case study is one of many similar incidents that can be found on Put yourself in the shoes of the participants: If you were the PCT in this situation, what would you have done? What if you were the staffer who tried to stop the fight—what would you have done to get the other two to calm down? If your employees had been involved, what do you think they would have done?

The Joint Commission (TJC) released a new report on January 28: Quick Safety 47: De-escalation in Healthcare. This report discusses better training to mitigate such situations. The accreditor writes that as violence against nurses, doctors, and healthcare staff becomes more prevalent, the need for mitigation is greater than ever. Violence and assault are perpetual risks for anyone working in healthcare, particularly nurses and nursing assistants. A three-year study in the American Journal of Nursing noted that 25% of nurses reported being assaulted by patients or family members of patients. Another study found the ED, geriatric, and psychiatric settings are the most prone to violent incidents.

This is just the latest push by TJC for hospitals to practice de-escalation as a means to stop workplace violence.

“The purpose of this Quick Safety is to present some de-escalation models and interventions for managing aggressive and agitated patients in the ED and inpatient settings,” they write. “There are many different de-escalation techniques; this Quick Safety is intended to guide health care professionals to resources for more information and training.”

The practice of de-escalation isn’t as heavily researched or defined as other best practices. Even TJC’s alert cautions that there’s been little research done on its effectiveness. However, the positive results of successfully de-escalating a situation are numerous, giving facilities reason to adopt the process.

These include:
Preventing violent behavior
Avoiding the use of restraint
Reducing patient anger and frustration
Maintaining the safety of staff and patients
Improving staff-patient connections
Enabling patients to manage their emotions and regain personal control
Helping patients develop feelings of hope, security, and self-acceptance

Spotting aggression
It’s not always immediately obvious when a person is becoming agitated or aggressive. Moods can change from compliant to hostile either instantaneously or gradually. Some people amp themselves up into violence, growing visibly angrier as the situation escalates. Others might look calm on the outside and seethe on the inside until they erupt.

The healthcare setting also plays a role in the types of aggression you might see. TJC notes that inpatient psychiatric facilities are more likely to have patients who exhibit risk-prone behaviors such as:
Verbal aggression
Escape attempts
Refusing to eat or drink
Displaying aggression to objects or people

This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor Journal.