2. Crisis Definition- All patients and visitors are in some type of perceived crisis when seeking medical attention.

3. Pre-Escalation Goal is to manipulate the environment to make it as inviting as possible and eliminate potential triggers

4. Strategy Staff need to identify an early pre-escalation strategy. Strategy can be introduced at earliest warning sign or even suggested on initial assessment Strategy is a calming mechanism to manage and minimize stress and to prevent a perceived crisis from escalating

5. Examples of Strategy Stress balls in a basket Coloring activities Stretching Deep breathing Music Reading materials Massage chair Rubber band on wrist Prayer books Run hands under cold or warm water Blankets Note cards Aromatherapy Games Progressive muscle relaxation Snacks on hand

6. Triggers A trigger is something that sets off a reaction. It could be anything that the patient associates with negative thoughts or feelings. Examples include: Loud voice Excessive hand motions People too close or attempting to touch Bedtime Men Not being listened to Lack of privacy Room checks

7. Early Warning Signs Early warning signs may be difficult to assess in a high stress/traffic area. Initial assessment is a key so a change from baseline behavior is recognized. - Restlessness - Agitation - Pacing - Shortness of breath - Sensing a tightness in the chest - Sweating - Becoming mute and dissociative

8. Examples of Early Warning Signs Restlessness Agitation Pacing Shortness of breath Sensing a tightness in the chest Sweating Becoming mute and dissociative Breathing hard Rocking Clenching teeth Wringing hands Bouncing legs Shaking Crying Giggling Heart pounding Singing Excessive eating Swearing

9. De-Escalation Person is already in crisis mode and starting to escalate. In phase one or two of crisis cycle Recognize possible transference and counter- transference interactions

10. De-Escalation Strategies Does initial Nursing assessment include a de- escalation assessment? Is it possible to designate an area to address sensory needs? If not, what about a comfort box? 75% reduction in restraints/seclusion over 2 year period after introduction of sensory sessions in a MA hospital

11. What Makes you Feel Upset? Circle all that make you feel sad, mad, scared or other Being touched Crowds Dark/night Time of day Time of year Yelling/shouting Storms Loud noises

12. How do I know I am Angry, Scared or Upset? Cry Clench Teeth Loud Voice Flush, hot face Rocking/withdraw/ preoccupy Pace/hyper Heart Pounding Clench fists Breath hard

13. HALT Easy acronym to employ in your training: H- Hungry? A- Angry? L- Lonely? T- Tired? Thirsty?

14. Case Studies Review case studies and discuss

15. Joint Commission and CMS Standards Comparing Joint Commission Restraint Standards and CMS Standards document Comparing Joint Commission Restraint Standards and CMS Standards document Common themes between hospital not deemed, deemed, behavioral health, and CMS guidelines. - Philosophy and definition - Appropriate staffing - Physician/LIP order - Monitoring and assessing the patient - Documentation - Staff training

16. Definition of Restraint Restraint= Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets or other methods that involve the physical holding of a patient for the purpose of conducting routine physical exam or tests, or to protect the patient from falling out of bed or to permit the patient to participate in activities w/out the risk of physical harm (this does not include a physical escort)

17. Definition of Seclusion Seclusion= the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self- destructive behavior.

18. Philosophy Vs. Practice Organization must develop a philosophy related to the use of seclusion and restraint Must ensure that practice supports philosophy

19. Other things to Include Trauma Informed Care Debriefing

20. Hands on Approach with a combative person Holds Take Down Lift Carry

22. Protective stance… Wide stance at legs (feet apart) and open arms/palms.

23. Blocking an over-head strike… Cross hands over head to block blow to head and deflect down.

24. Blocking a Kick… Rotate body so kick strikes lateral side of leg. video

25. Blocking a Punch Block punch between shoulder and elbow and between elbow and wrist; keep moving in downward direction of fist. video

26. Biting… Push and hold head into bite.

27. Ponytail hair pull… Grab arm and stabilize hands to head, then bend forward to throw them off balance. video

28. Hair Pull… Stabilize hair pull and bend forward to promote release. video

29. Choking or strangle… Lift arms, shrug shoulders and twist out for release. video

30. Choke from behind… Lean forward as you bump with your hip and back out of hold. video

32. Restrain and Walk… Hold under arms and hold at wrist, push hip into person and walk forward keeping hip pressure. video 1video 1, video 2, video 3video 2video 3

33. Take Down… Hold under arms and at wrist; place inside leg behind calf; rotate backwards and take down to the floor; third staff member protects head. video

34. Roll over onto abdomen… Roll in the direction of crossed leg. Person at the head checks airway. *see next slide for complete video

35. Lift… Support under arms, link with staff at the head, 2 staff members support and lift legs (knees and ankles). video