1. 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.

2. 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. ►►► Addressing Combative Patients

3. 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

4. Agenda: ► Epidemiology of combative behavior ► Responding to the threat of violence Course Agenda

5. The Epidemiology of Combative Behavior Section 1

6. Definition NIOSH defines workplace violence as violent acts directed toward persons at work or on duty: ► Examples: –Threats –Physical assaults –Muggings

7. 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

8. Predicting Violent Behavior Warning signs: ► Pacing or restlessness ► Clenched fist ► Increasingly loud speech ► Excessive insistence ► Threats ► Cursing

9. 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

10. 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

11. 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

12. Who is at Risk? Personnel at high risk: ► Nurses ► Aides Personnel at increased risk: ► Emergency response ► Safety officers ► Healthcare providers

13. Where May Violence Occur? Areas violence frequently occurs: ► Psychiatric wards ► Emergency rooms ► Waiting rooms ► Geriatric units

14. Responding to the Threat of Violence Section 2

15. Prevention Strategies Five progressive strategies: ► Administrative controls ► Verbal de-escalation ► Seclusion ► Physical restraints ► Medication

16. 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

17. 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

18. 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

19. Escalating Behavior Escalating behavior: ► Be consistent ► Patients may attempt to split staff

20. Defining Limits Verbal de-escalation should include: ► Defined limits ► Consequences

21. Signs of Impending Violence Warnings of impending violence: ► Changes in patient mood ► Loud or aggressive speech ► Increasing psychomotor activity ► Signs not always evident

22. Unsuccessful De-Escalation If less restrictive efforts fail: ► Restraints ► Seclusion ► Medication

23. Moving Beyond Verbal De-Escalation To go beyond verbal de-escalation: ► Sufficient trained personnel ► Treat patients with dignity

24. 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

25. 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

26. Managing the Secluded Patient The patient should be: ► Reminded of consequences ► Monitored at least every 15 minutes ► Monitored by closed-circuit television, if available

27. Principles of Physical Restraint Principles of patient restraints: ► Individualized and afford dignity ► Humanely administered ► Protocols developed ► Usage carefully documented ► Least restrictive necessary

28. 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

29. 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

30. The Risk of Medication Risks of using medications: ► Introduce complications ► Obscure physical exam

31. 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

32. Additional Information ►Section 3

33. 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 Additional Information