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Pediatric Hospital Medicine 2014: Behavioral Emergencies: Stay Safe, Stay Calm


David Pressel, Jessica Tomaszewski, Emily Fingado, Adam Pressel


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

Patients with underlying psychiatric or developmental disorders, have ingested substances, or have a medication side effect are at highest risk for becoming violent. Triggers for these events could be due to 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.

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 JCAHO 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 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.

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

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

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