1. Addressing Combative Patients
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Welcome to the Addressing Combative Patients presentation.

2. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
We have very specific learning objectives for you during this presentation.
At the conclusion of this presentation, you will:
Recognize the potential for encounters with combative patients.
Possess options to evaluate, control, and defuse the situation. 2

3. Course Agenda Agenda: Epidemiology of combative behavior
Responding to the threat of violence
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Our presentation today will involve the following agenda:
We will discuss The Epidemiology of Combative Behavior.
We will examine options for Responding to the Threat of Violence. 3

4. The Epidemiology of Combative Behavior
Section 1
The Epidemiology of Combative Behavior

5. Definition
NIOSH defines workplace violence as violent acts directed toward persons at work or on duty:
Examples:
Threats
Physical assaults
Muggings
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Welcome to Section One.
Violent behavior constitutes any set of actions that are forceful or directed enough to cause injury to the patient or others.
Workplace violence ranges from offensive or threatening language to homicide.
The National Institute for Occupational Safety and Health (or NIOSH) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.
Examples of violence include the following:
Threats – Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats.
Physical assaults – Attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs, or knives.
Muggings – Aggravated assaults, usually conducted by surprise and with intent to rob.

6. Frequency Over 5 million in the U.S. work in healthcare:
Exposed to many safety and health hazards
High risk for experiencing workplace violence
Bureau of Labor Statistics (BLS) estimates assaults four times higher than other industries
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
More than 5 million U.S. workers perform many different occupations in the healthcare industry.
They are exposed to many safety and health hazards, including violence.
Studies have indicated that healthcare workers are at high risk for experiencing violence in the workplace.
According to estimates performed by the Bureau of Labor Statistics (BLS), hospital workers are assaulted at rates approximately four times the average for other private-sector industries. 6

7. Predicting Violent Behavior
Warning signs:
Pacing or restlessness
Clenched fist
Increasingly loud speech
Excessive insistence
Threats
Cursing
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
This will come as no surprise, but a history of violent behavior is the most uniform predictor of violent behavior.
Many facilities have implemented systems for documenting and notifying staff about patients with a history of violence.
Other warning signs of impending violence include:
Pacing and/or restlessness
Clenched fist
Increasingly loud speech
Excessive insistence
Threats
Cursing 7

8. Delaying Care Major problems of combative patient:
Potential for injury
Delay in care
Behavior may be result of medical or surgical condition:
Treat agitations, resolve behavioral problems
Address behavior then care
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
There are at least two major problems posed by the combative patient.
The obvious problem is the potential for injury to the patient, staff, or other persons in the vicinity.
The other problem is the delay in care caused by having to deal with the threat of violence.
Remember that the undesired behavior being displayed by the patient may be the result of a medical or surgical condition.
Treatment of conditions that may cause agitation, such as hypoxia, may in fact resolve behavioral problems.
But often, the behavior itself will need to be addressed before definitive care can take place.
Once the potential for violence is neutralized, care and treatment can be completed. 8

9. 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 incident reporting and recordkeeping
Establishes a plan for maintaining security
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Universal Precautions for violence states that violence should be expected, but can be avoided or mitigated through preparation.
It is imperative to have a clearly defined approach for dealing with the threat of violence and actual combative patients in the healthcare setting.
OSHA recommends that employers establish and maintain a violence prevention program as part of their facility's safety and health program.
The prevention program should be made available to all employees, including managers and supervisors, and all employees should receive specific training concerning its content and implementation.
The written violence prevention plan should state clear goals and objectives suitable to the size and complexity of the given workplace.
Although not every incident can be prevented, many can be, and the severity of injuries sustained by employees reduced by following a violence prevention plan.
A violence prevention written plan:
Creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be tolerated.
Ensures that no reprisals are taken against employees who report or experience workplace violence.
Encourages prompt reporting of all violent incidents and recordkeeping of incidents to assess risk and to measure progress.
Establishes a plan for maintaining security in the workplace which includes law enforcement officials and other specialists. 9

10. Activities Related to Violence
Violence often takes place during:
Meal times
Visiting hours
Patient transportation
Assaults may occur when:
Service is denied
Patient is involuntarily admitted
Limits set on eating, drinking, tobacco, or alcohol use
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Studies indicate that violence most often takes place during times of high activity and interaction with patients, such as at meal times and during visiting hours and patient transportation.
Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use.
Many patients that are combative are in an agitated state associated with low blood sugar, chemical imbalance, or the use of a stimulant such as cocaine or PCP. 10

11. Who is at Risk? Personnel at high risk: Nurses Aides
Personnel at increased risk:
Emergency response
Safety officers
Healthcare providers
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Although anyone working in the healthcare setting may become a victim of violence, nurses and aides who have the most direct contact with patients are at higher risk.
Other personnel at increased risk of violence include emergency response personnel, safety officers, and all healthcare providers. 11

12. Where May Violence Occur?
Areas violence frequently occurs:
Psychiatric wards
Emergency rooms
Waiting rooms
Geriatric units
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Violence may occur anywhere in a healthcare facility, but it is most frequent in the following areas:
Psychiatric wards
Emergency rooms
Waiting rooms
Geriatric units
Of course, outside of the healthcare facility, paramedics and firefighters can routinely encounter combative patients. 12

13. Responding to the Threat of Violence
Section 2
Responding to the Threat of Violence

14. Prevention Strategies
Five progressive strategies:
Administrative controls
Verbal de-escalation
Seclusion
Physical restraints
Medication
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Welcome to Section 2.
We’re going to discuss five different, but related, strategies for dealing with the combative patient.
These five strategies provide us with the best assurances for the safety of patients and staff.
These progressive strategies include:
Administrative controls
Verbal de-escalation
Seclusion
Physical restraints
Medication
Let’s discuss these five strategies. 14

15. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
The phrase “least restrictive alternative” is commonly encountered during any discussion of the management of combative patients.
This doctrine states that 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. 15

16. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Administrative controls help manage the work environment in such a manner as to reduce the potential for a person to become combative.
Administrative controls include:
Design waiting areas to accommodate and assist visitors and patients who may have a delay in service.
Minimizing bright lights, blaring radios or TVs, intrusive loud speaker messages, heavy traffic, and other environmental factors that may cause agitation.
Arranging furniture and other objects to minimize their use as weapons.
An administrative control can also be ensuring adequate staff present at the scene so the patient clearly sees they are outnumbered. 16

17. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
When interacting with a potentially combative patient, the three main themes to continually convey are:
Express concern for the well-being of the patient.
Emphasize that the staff is in control.
Reassure that no harm will come to the patient.
However, always maintain a means of egress – you should be closer to the door than the patient.
Be aware of body language – crossed arms, hands behind the back, a forward leaning frontal posture, prolonged or intense eye contact can be perceived as threatening or challenging. 
When speaking to at risk patients, it is important to maintain a calm, controlled tone without being overly authoritarian or demeaning. 17

18. Escalating Behavior Escalating behavior: Be consistent
Patients may attempt to split staff
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
It is critical that all healthcare providers be consistent in their approach to combative patients.
Manipulative patients may attempt to split staff who do not have a unified strategy 18

19. Defining Limits Verbal de-escalation should include: Defined limits
Consequences
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
During the attempts at verbal de-escalation, clearly defined limits for patient behavior should be expressed, as well as consequences of their actions if they choose to ignore these limits. 19

20. Signs of Impending Violence
Warnings of impending violence:
Changes in patient mood
Loud or aggressive speech
Increasing psychomotor activity
Signs not always evident
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
We discussed some predictors of violence earlier in this presentation.
However, it is not always possible to know when a patient may become combative.
Always be alert for changes in patient mood, loud or aggressive speech or actions, increasing psychomotor activity, which may signal impending loss of control.
The ultimate gauge for impending danger is your perceptions – if you feel threatened in the face of a potentially hostile patient, it is best to abort the current interaction in favor of a more managed situation. 20

21. Unsuccessful De-Escalation
If less restrictive efforts fail:
Restraints
Seclusion
Medication
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Sometimes, in spite of your best efforts at de-escalation, patient behavior will deteriorate.
If less restrictive efforts are unsuccessful, restraints, seclusion, and/or medication may be used in response to imminently dangerous behavior. 21

22. Moving Beyond Verbal De-Escalation
To go beyond verbal de-escalation:
Sufficient trained personnel
Treat patients with dignity
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
If the situation continues to escalate towards violence, a decision must be made to initiate a more aggressive approach, including seclusion, restraints, and/or medication.
The use of seclusion and restraints, both physical and chemical, is a last resort for maintaining the safety of patients, visitors, and treatment personnel, and should be utilized only when clearly indicated by a policy detailing specific criteria.
To implement these strategies, there must be a sufficient number of trained personnel involved so that the procedure can be carried out safely and effectively.
Involved personnel should be proficient enough with these procedures that they convey confidence, calmness, and proceed with implementation as if it were a routine procedure.
The Centers for Medicare and Medicaid Services’ manual on day-to-day operating instructions, policies, and procedures states, “A restraint or seclusion for behavior management is used only as an emergency measure and is reserved for those occasions when severely aggressive, combative, or destructive behavior places the patient or others in imminent danger.”
Seclusion and restraints are not to be used for disciplinary purposes or as a standing order.
When there is a need to utilize seclusion or restraints, facilities should treat patients with the utmost dignity and respect and protect them from humiliation. 22

23. Seclusion Seclusion serves to: Decrease external stimuli
Permit time to regain control
Seclusion is not good if patients:
Have unstable medical conditions
Need close interaction or monitoring
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Seclusion serves to decrease external stimuli and permits the patient time to regain control of their behavior.
A literature review of the topic indicates that most seclusion occur on the first day of hospitalization, with the four most common reasons being agitation, uncooperativeness, anger, and history of violence.
Seclusion is not a good option for patients with unstable medical conditions or who require close physical interaction or monitoring. 23

24. Preparing for Seclusion
Pay attention to environment:
“Sharps”
Artificial, natural lighting
Cooling, heating, ventilation
Toilet facilities, bed and cleanness
How staff will see and communicate
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
When a patient is to be secluded, it is important that great care and attention be paid to the physical environment.
All too often, the room is checked for “sharps” and other objects that could be used for self harm.
However, very little attention is paid to things such as artificial or natural lighting, cooling, heating, ventilation, toilet facilities, access to a bed, and a way for staff to see and to communicate with the patient while they are in the seclusion room.
It is essential that patients know how to communicate with staff, should a medical emergency arise while they are in seclusion and require assistance, and that staff respond to these requests immediately.
Many patients find seclusion rooms to be unpleasant, and therefore, there is the potential that this will amplify or perpetuate the behavior which precipitated seclusion as well as exacerbating the patient’s fear and anxiety.
In some facilities, the seclusion rooms are located beside or near the nursing station, but this also can be in a noisy, high volume traffic area and the patient may find the noise to be disturbing, distracting, or more stimulating than they can handle.
Consideration should be given to locating seclusion rooms in an area that is quiet, private, and where the privacy of the patient can be protected at all times while allowing clinical staff to provide the appropriate level of observation and care.
There is a need for the room to be kept clean, free of spills, and to have meal trays removed promptly.
Regular inspections and cleaning of the room should be conducted.
This will contribute to reducing the health and safety risks associated with an unkempt room.
It will also minimize risk should the staff need to enter the room to deal with a high risk situation. 24

25. Managing the Secluded Patient
The patient should be:
Reminded of consequences
Monitored at least every 15 minutes
Monitored by closed-circuit television, if available
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
The door to the seclusion area does not necessarily have to be closed, but should be closed if the behavior continues and closing the door becomes necessary to maintain order in the work environment.
The patient should be continually reminded of the consequences of their behavior and be provided with ample opportunity to comply with instructions and expectations in order to be released from seclusion.
Medication may be included with the seclusion strategy in order to avoid further restrictive measures.
The status of the patient in a seclusion area should be monitored at least every 15 minutes, or monitored by closed-circuit television if available. 25

26. Principles of Physical Restraint
Principles of patient restraints:
Individualized and afford dignity
Humanely administered
Protocols developed
Usage carefully documented
Least restrictive necessary
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that the individual cannot remove easily, which restricts freedom of movement, or normal access to one’s body.
Examples include, but are not limited to, leg restraints, arm restraints, vest or jacket restraints, waist belts, geri-chairs, hand mitts, wheelchair safety bars, and lap pillows.
Practices which meet the definition of a restraint include tucking in a sheet so tightly that a patient cannot move, bedrails, or chairs that prevent a patient from rising, or placing a wheelchair bound patient so close to a wall that the wall prevents the patient from rising.
The implementation of physical restraints is dangerous for both staff and patient.
Once the decision is made to proceed with physical restraints, negotiations should be halted and implementation should be swift, humane, and carried through to completion.
It should never be attempted unless there is sufficient manpower to entirely control the process.
Securing each limb would, for example, require a minimum of 5 staff members, one for each limb plus a team leader.
Patient restraint involves issues of civil rights and liberties, including the right to refuse care, freedom from imprisonment, and freedom of association.
However, there are circumstances when the use of restraints is in the best interest of the patient, staff, or the public.
The following principles apply to patient restraints:
Restraints should be individualized and afford as much dignity to the patient as the situation allows.
Any restraints should be humanely and professionally administered.
Protocols to ensure patient safety should be developed to address observation and treatment during the period of restraint and periodic assessment as to the need and means of restraint.
The use of restraints should be carefully documented. Such documentation should include the reasons for and means of restraint and the periodic assessment of the restrained patient.
The method of restraint should be the least restrictive necessary for the protection of the patient and others. 26

27. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Once the patient is controlled, a thorough physical exam should be performed, if not yet completed.
Policies should be established to address the frequency and parameters of patient monitoring while in restraints.
Monitoring should evaluate the need for continued restraints.
Distal circulation should be checked frequently and restraints adjusted as necessary.
After the patient is in control, the staff can decide to remove the restraints one limb at a time, while monitoring the patient for behavioral control. 27

28. 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
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
There are times that medication may be necessary in addition to physical restraint.
This would include continued high risk behavior, such as spitting, biting, disruptive verbal threats, and struggling against the restraints and medical care.
A discussion of medication usage for combative patients is well beyond the scope of this program.
Ultimately, however, the choice of which medication to use for behavior control is far less important, and less complicated, than the decision to use medication in the first place.
The goal for medication usage with a combative patient is simply to control behavior, without over sedation, without loss of airway or cardiovascular stability, such that patient evaluation and treatment can be performed.
It is effective for violent behavior due to psychiatric, emotional, or medical causes.   28

29. The Risk of Medication Risks of using medications:
Introduce complications
Obscure physical exam
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
The use of sedating medications for combative patients may introduce complications or obscure the physical exam.
However, in many cases the risk of over sedation is outweighed by the risk of continued struggle, for instance, in the case of an intoxicated patient with a potential spinal injury. 29

30. Documenting Behavioral Control
Documentation includes:
The emergency and explanation for treatment
Refused or unable to give consent
Evidence of incompetence to refuse treatment
Failures of less restrictive methods of control
Explain techniques used and any injuries incurred
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
The legal measure for overriding a patient’s right to refuse medication, seclusion, or restraint in response to combative behavior is that it must be deemed to be in the patient’s best interest.
If behavior control is carried out against patient’s wishes, there is an obligation to document the reasons.
The information that should be documented includes:
An emergency existed.
The need for treatment was explained to the patient (regardless of competence).
The patient refused treatment or was unable to consent to treatment.
Evidence of the patient’s incompetence to refuse treatment.
Failures of less restrictive methods of control (such as verbal de-escalation).
The techniques were used for the safety of the patient or others.
The reasons for the behavior control were explained to the patient (regardless of competence).
The type/method of technique used.
Any injuries that occurred during the procedure. 30

31. Additional Information
Section 3
Additional Information

32. Additional Information
Violence: Occupational Hazards in Hospitals. National Institute of Occupational Safety and Health (NIOSH) Publication No , (2002, April)
Center for Medicare and Medicaid Services website:
ww.cms.gov
Recommended Facilitator Notes: (read the following text out-loud to participants while showing this slide)
Here are some sources of additional information on this important topic.
Please reference them to continue your learning on this subject. 32