Derail Behavioral Emergencies in Hospitals



Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Key Takeaway

Hospitalists should ensure that their home institutions have developed policies and procedures, as well as ongoing training to address patient behavioral emergencies.

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