How to De-Escalate a Patient Like a Boss


#1

It doesn’t matter whether you work in psych or med-surg, women or peds, ICU or the ED… from time to time, patients everywhere go absolutely ape-shit.

 

Safety

It sounds like an NCLEX question but it's true that your first priority is not only safety of your patient but that of yourself and other staff as well. If the patient is physically attacking someone or about to physically harm themselves, they will need to be restrained.

 

Code Atlas

Many hospitals use the term "Code Atlas" to refer to a situation requiring backup. That backup is typically police/security, supervisors, and a lot of people (usually dudes) that show up from nearby units to offer assistance.

Sometimes the sheer presence of a group of people is enough to stop a patient from physically fighting someone, but it’s better to know that you won’t be alone if they do decide to kick things up a notch.

 

Restraints

Best if you can avoid them, but if someone is incapable of being calmed you're going to need to put them in restraints if they are a physical danger to themselves or others.

Don’t try to put a patient in restraints until your backup is around, and it’s best if everyone gets one limb… don’t forget the legs, people do kick as well as punch.

Restraints will mean more paperwork and more assessment time on your part, so avoid them if you can. Also be sure to have them just tight enough without cutting off circulation by using the two-finger rule.

 

Involve the doctor

Sometimes these situations can be resolved by a one time dose of pain medicine or an anxiolytic-like Ativan. Sometimes heavier sedation is needed for patient and staff safety like Haldol or Geodon.

By having the patient’s doctor aware of the issue, you can quickly get what you need to swiftly resolve the matter.

 

Refreshments

Before shit gets too crazy with a takedown and restraints, try to ask your patient if there is anything you can get for them. The easiest wishes to meet involve food and drinks.

Having worked in psych, our managers told us that many patients can be calmed from having something to drink or eat… think Maslow’s hierarchy of needs.

 

Give them space

If the patient is not an immediate danger to themselves or others, give them some space to try to calm down and rationalize the situation.

By limiting the amount of stimulus (and people) in the room, the patient may be less likely to go off.

 

Remain calm

Many patients, especially psych ones, have a history of trauma. You want to approach these individuals with a calm and non-threatening demeanor, as anything loud or threatening will trigger their past trauma and abuse and set them off.

The patient may yell and become verbally abusive. Don’t take anything they say personally, as they are simply blowing off steam, and might even apologize to you soon after they settle down.

 

Document everything

Like everything else in the medical field, someone having a meltdown is no exception to the rule... document that janx!

Be as objective as you can, and keep it to just the facts.

 

Why are they upset?

Discover the root of the problem. Many patients will flip out related to a loss of control which is common in a hospital setting.

Try to allow a patient to reclaim some control (or get their way) while still adhering to their medical plan of care.

 

Offer multiple options

Nobody likes being told what to do and what not to do. I know there are times when a patient's expectations are insane and unrealistic, but it's your job to offer them realistic goals that you can actually follow through on.

Give the patient some autonomy by being able to choose from a few alternative options that are all achievable. This assures that whatever option they choose they are still doing something that you are okay with, while simultaneously letting them think they are in control.

 

You're on their side

Remind the patient that you are on their side and that everyone else is just trying to help.

We are not the enemy, but sometimes there is simply nothing we can do to satisfy a patient, so don’t take it personally.

 

AMA

In the event that the patient is of sound mind and not TDO'd or otherwise legally obligated to remain in the hospital, it is their right as a patient to sign an AMA sheet and leave.

We cannot and will not hold such a patient against their will… ain’t nobody got time for that! Bye, Felicia!