The Art of De-escalation: Managing Agitated Patients in the Emergency Department.

Introduction:

Patients often exhibit agitation in hospital set-ups that need to be intervened immediately with a lot of patience, which may otherwise lead to untoward incidents. Recent studies encourage more non-coercive (not forcing or entrusting a person to do things) than conventional techniques like treating using physical restraints and pharmacotherapy, as the former method has shown more promising results. The non-coercive approach believes in engaging the patient verbally, followed by an attempt to establish cooperative behavior, making the patient come out of the agitation zone using verbal de-escalation.

What Is De-escalation?

A de-escalation is a verbal act of engaging the patient, making him or her come out of the agitation zone, and encouraging him or her to be involved actively and cooperate with the treatment and evaluation process.

How Should an Emergency Psychiatry Physician Approach an Agitated Patient?

Managing an agitated patient is based on four important basic principles, which include,

• Ensuring the safety of the agitated patient, staff, and others who are in close contact with the agitated patient.

• Engaging the patient verbally and making him feel comfortable and helping him in managing his emotions.

• Restraint usage should be avoided as far as possible.

• Avoid coercive or provocative methods that escalate agitation.

What Are the De-escalation Guidelines Followed to Manage Agitated Patients?

Respect Patient’s and Clinician’s Personal Space:

• When managing an agitated patient, a minimum of two arm's length distance between the clinician and the patient should be maintained.

• Maintaining distance will give space for both the doctor and the patient, as it makes the patient feel safe and also lets the doctor move out when the patient tries to attack.

• Both the patient and the clinician should not indulge in blocking each other's way, especially in the case of patients who want the distance to be maintained. This approach seems to make one comfortable with the surroundings before getting the proper treatment.

• Most of the agitated patients have a history of trauma or assaults, which makes them feel restless when personal space is not given.

Not to Be Provocative:

• The body language of the clinician and other medical staff plays an important role in managing an agitated patient.

• Body language traits like visible hands without clenching while speaking, avoiding concealed hands, and avoiding excess eye contact or staring may make the patient feel offended. Having a closed body language will make the patient feel a lack of interest towards them and may not feel comfortable cooperating for further treatment.

• The clinician’s body language should always match his or her attitude while treating a patient so that the patient feels genuine and starts feeling comfortable.

• Humiliation should never be practiced as this causes an aggressive nature in the patient, who may feel that their integrity is compromised, which again makes the patient feel agitated.

To Establish Verbal Contact:

• The doctor or the health professional dealing with the agitated patient should be well-trained and carry out the art of de-escalation smoothly. Many people interacting verbally with the patient to de-escalate should be avoided, as it will make the patient more conscious and, in turn, lead to escalation.

• Starting the conversation politely is the first step in establishing contact with the agitated patient.

• Assuring the patient that they are in safe hands and they are present in the hospital set-up to get treated and not be harmed should be conveyed with polite verbal and body language.

• Everyone wants to be called by their name. Calling the patient by name will establish a good rapport.

• However, in the case of agitated patients, before proceeding, deciding whether to call by the patient’s first name or last name is critical as the patient may find it monotonous and fail to establish a connecting bond with the doctor through verbal communication.

• Also, asking the patient whether he or she prefers being called by the first name or last name will make him or her feel that they are given importance, as the patient tends to have a feeling of authority or control over the situation.

Being Concise:

• Agitated patients are slow to grasp and process the information; using more concise and simpler vocabulary will make them understand better. Giving them enough time to respond will make them feel comfortable and avoid uneasiness.

• Giving them enough time to respond will make them comfortable and avoid uneasiness.

• Since the agitated patient is slow in grasping the information, repetition of the requests or maybe even setting the limits should be emphasized.

• Often, repetition should be associated with listening and cooperative skills whenever it is feasible.

Identifying Wants and Feelings:

• Identifying the patient’s wants and needs will reduce the anxiety of the agitated patient.

• The patient’s body language and what they express through the conversation should be carefully examined, and a lot of free information can be obtained, which helps the clinician identify the wants and feelings of the patient.

• The free information obtained will make the clinician more empathetic towards the patients, expressing the willingness to help the patient in fulfilling his or her needs, thus de-escalating the agitation from the patient.

Listening Closely to the Patient:

• Making the patient aware of the fact that the clinician is paying close attention to the conversation is an important step in the process of de-escalating the agitation.

• The clinician, through verbal acknowledgment and body language, can show concern.

• By doing this, the patient may feel cared for and engage in the conversation and may reveal the reason for the agitated behavior.

Agreeing to the Disagreement:

• The agitated patient usually wants someone to believe what they are conveying, which might not always be right. Confronting the wrong notion outright will make the patient more agitated.

• To avoid an empathetic behavior of finding some truth or principle about what the patient is saying and agreeing to it if it is right can lead to a better understanding between the doctor and the patient.

Laying Down the Law and Setting the Limits:

• The patient should be well informed about the fact that causing injury to oneself or others present is not tolerated and can also undergo punishment for doing the same. The method of conveying should rather be firm and jurisdiction and not in a threatening tone.

• Conveying the actual reason, that is, the desire to help the patient, should be demonstrated, and expressing that the doctor can not help if the patient shows bad behavior is vital in making the patient understand the genuineness of the clinician’s approach.

Offering Choices and Optimism:

• Offering choices to an agitated patient who is in a state of anxiety and cannot understand anything can calm the patient.

• An agitated patient who believes that violence is the answer or necessary response should be allowed to choose by which they can be diverted or distracted from being even more anxious.

• Offering choices can include blankets, magazines, and access to a phone, and offering food and drink can be perceived as an act of kindness towards the patient to ward off the aggressive behavior.

Debriefing the Patient and the Staff:

• The patient needs to be debriefed about the need for an involuntary intervention.

• The clinician should convince the patient why it is necessary and can also suggest to the patient that the previous option (involuntary intervention) can be avoided if the patient cooperates the next time.

• StaIf also needs to be debriefed about the involuntary procedure. Suggestions and feedback on the restraint treatment from the staff are considered to conduct such procedures in a more precise way in the future.

Conclusion:

Verbal de-escalation techniques have proved to be more meaningful and potent in reducing anxiety and keeping the patient calm while delivering medical care in the emergency set-up. The agitated patients are treated without coercive interventions like forced medications and using physical restraints, making the patient more cooperative and building trust in the caregivers, rendering them to seek medical care more confidently in the future, avoiding repetitive agitating episodes.