FHM TRAINING TOOLS
This training presentation is part of FHM’s
commitment to creating and keeping safe
workplaces.
Be sure to check out all the training programs
that are specific to your industry.
Addressing Combative Patients
►►►
These materials have been developed based on applicable federal laws and regulations in place at the time the materials were created. The program
is being provided for educational and informational purposes only and does not constitute and is not intended to provide OSHA compliance certification,
regulatory compliance, a substitute for any "hands on“ training required by applicable laws and regulations, or other legal or professional advice or
services. By accessing the materials, you assume all responsibility and risk arising from the use of the content contained therein.
©2010 Grainger Safety Services, Inc.
Learning Objectives
At the conclusion of this
presentation, you will:
► Recognize
potential for encounters
with combative patients
► Possess
options to evaluate,
control, and defuse situations
Course Agenda
Agenda:
► Epidemiology
► Responding
of combative behavior
to the threat of violence
Section 1
The Epidemiology
of Combative
Behavior
Definition
NIOSH defines workplace violence as violent acts
directed toward persons at work or on duty:
► Examples:
– Threats
– Physical assaults
– Muggings
Frequency
Over 5 million in the U.S. work in healthcare:
► Exposed
► High
to many safety and health hazards
risk for experiencing workplace violence
► Bureau
of Labor Statistics (BLS) estimates assaults
four times higher than other industries
Predicting Violent Behavior
Warning signs:
► Pacing
or restlessness
► Clenched
fist
► Increasingly
► Excessive
► Threats
► Cursing
loud speech
insistence
Delaying Care
Major problems of combative patient:
► Potential
► Delay
for injury
in care
Behavior may be result of medical or
surgical condition:
► Treat
agitations, resolve behavioral
problems
► Address
behavior then care
Establishing a Clear Approach
OSHA recommends that employers establish and
maintain a written violence prevention plan:
► Creates
a policy that violence will not be tolerated
► No
reprisals against employees reporting or
experience violence
► Encourages
► Establishes
incident reporting and recordkeeping
a plan for maintaining security
Activities Related to Violence
Violence often takes place during:
► Meal
times
► Visiting
hours
► Patient
transportation
Assaults may occur when:
► Service
► Patient
► Limits
is denied
is involuntarily admitted
set on eating, drinking,
tobacco, or alcohol use
Who is at Risk?
Personnel at high risk:
► Nurses
► Aides
Personnel at increased risk:
► Emergency
► Safety
response
officers
► Healthcare
providers
Where May Violence Occur?
Areas violence frequently occurs:
► Psychiatric
► Emergency
► Waiting
wards
rooms
rooms
► Geriatric
units
Section 2
Responding to the
Threat of Violence
Prevention Strategies
Five progressive strategies:
► Administrative
► Verbal
controls
de-escalation
► Seclusion
► Physical
restraints
► Medication
Least Restrictive Alternative Doctrine
Least restrictive alternative doctrine:
► Individuals
should be provided with
any necessary care, treatment, and
support in the least invasive
manner, and in the least restrictive
manner and environment compatible
with the delivery of safe and
effective care, taking into account,
where appropriate, the safety of
others
Administrative Controls
Administrative controls include:
► Design
waiting areas to
accommodate for delays
► Minimize
bright lights, loud radios,
TVs, speaker messages, heavy
traffic
► Arrange
furniture and other objects
to minimize their use as weapons
► Ensure
adequate staff at scene
Verbal De-Escalation
Three main themes to continually convey:
► Express concern for patient well-being
► Emphasize staff in control
► Reassure no harm
Also:
►
Maintain a means of egress
►
Vigilant of body language
►
Maintain calm, controlled tone
Escalating Behavior
Escalating behavior:
►Be
consistent
►Patients
may attempt to split staff
Defining Limits
Verbal de-escalation should include:
► Defined
limits
► Consequences
Signs of Impending Violence
Warnings of impending violence:
► Changes
► Loud
in patient mood
or aggressive speech
► Increasing
► Signs
psychomotor activity
not always evident
Unsuccessful De-Escalation
If less restrictive efforts fail:
► Restraints
► Seclusion
► Medication
Moving Beyond Verbal De-Escalation
To go beyond verbal de-escalation:
► Sufficient
► Treat
trained personnel
patients with dignity
Seclusion
Seclusion serves to:
► Decrease
► Permit
external stimuli
time to regain control
Seclusion is not good if patients:
► Have
unstable medical conditions
► Need
close interaction or monitoring
Preparing for Seclusion
Pay attention to environment:
► “Sharps”
► Artificial,
natural lighting
► Cooling,
heating, ventilation
► Toilet
► How
facilities, bed and cleanness
staff will see and communicate
Managing the Secluded Patient
The patient should be:
► Reminded
of consequences
► Monitored
at least every 15 minutes
► Monitored
by closed-circuit
television, if available
Principles of Physical Restraint
Principles of patient restraints:
► Individualized
► Humanely
► Protocols
► Usage
► Least
and afford dignity
administered
developed
carefully documented
restrictive necessary
Managing the Restrained Patient
Establish parameters of patient
monitoring while in restraints:
► Monitor
need for continued restraint
► Check
distal circulation frequently,
adjust as necessary
► Remove
one limb at a time
Medication
Medication:
► In
addition to physical restraint
► Control
behavior to perform evaluation
and treatment
► Effective
for violent behavior due to psychiatric,
emotional, or medical causes
The Risk of Medication
Risks of using medications:
► Introduce
► Obscure
complications
physical exam
Documenting Behavioral Control
Documentation includes:
► The
emergency and explanation for treatment
► Refused
or unable to give consent
► Evidence
► Failures
► Explain
of incompetence to refuse treatment
of less restrictive methods of control
techniques used and any injuries incurred
►Section 3
Additional
Information
Additional Information
Violence: Occupational Hazards in
Hospitals. National Institute of
Occupational Safety and Health
(NIOSH) Publication No. 2002-101,
(2002, April)
Center for Medicare and Medicaid
Services website:
ww.cms.gov