Defusing Volatile Patient Situations

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Previously published in the IAHSS Journal of Protection Management Journal.
Author: Timothy J. Quist, VP of Healthcare Security, Virginia

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The author, an advocate of an approach to healthcare security solutions that emphasizes compassion and safety in the sensitive healthcare environment, describes how a strike team of security, behavioral health and ED staff was able to collaboratively defuse situations with combative patients without resorting to forceful hands-on action.

As the role of healthcare security officers has evolved in the hospital setting, excellent customer services skills are more important now than ever before. Security officers must manage the delicate balance between congenial customer interaction, with the challenging responsibility of assisting with difficult patients, visitors and staff.

In the past, there was a rush for forceful hands-on action with persons creating a disturbance or with a behavioral health patient acting-out and in need of medication. While this was an accepted practice in some settings, more and more we realized that this approach can often be avoided. With the proper training, security staff can effectively deal with individuals who may be combative by simply taking the time to defuse the situation and demonstrate a calm respectful response to the patient.

As a former hospital director of security, it was clear that being called to the behavioral health unit when patients were disruptive meant that security officers were expected to place hands on the individual and hold him down until he was medicated. The strategy of calmly talking with the patient was almost non-existent and unexpected.

Discussions between the patient care director and myself quickly resulted in agreement that we needed to change our habits of forceful intervention before someone was injured. We collaboratively started teaching the security officers about different types of conditions, what to expect when certain situations occurred, and how to best handle each situation.

INTEGRATING SECURITY AND POLICE OFFICERS IN CRISIS INTERVENTION

We also worked with the local law enforcement officers to integrate our security supervisors into their Crisis Intervention Training (CIT). This was a weeklong course that placed security officers side-by-side with local police and the sheriff’s office to learn more about management of behavioral health patients and more effective intervention. CIT training also had officers interact with former patients who had experienced altercations with police in the past and how that experience felt to them. This CIT exposure and additional training not only complemented our CPI training, it was also a great way for security officers to get to know the local police officers and create stronger relationships on a new level. Sharing experiences and exchanging information helped each person know how the other might react when combative patients are encountered.

CHOOSING THE RIGHT LEAD PERSON

The next step was to determine how each situation is different — and in most situations how choosing the right person makes a big difference in outcomes. We learned to stop before entering a combative patient’s room to conduct a quick assessment of the situation. We determined the best lead person to handle the issue based on a quick observation. The other team members did not demonstrate an overwhelming show of force when the lead individual talked to the patient.

Sometimes the lead person turned out not to be the right person. That was easily discernible by how the situation escalated. Just like a good baseball game, we called in the relief pitcher and the next most qualified person assumed the role of leader.

Observing the response to the initial leader helped us identify what was most likely upsetting the patient or escalating the situation. This helped us better understand who we needed to send in as a replacement lead to calm the patient and de-escalate the situation. Sometimes this meant that we had to take a few more minutes on the call, but it was worth the time. We were able to typically reduce the number of people needed to contain and resolve the situation, which helped reduce the number of resources required from other departments of the hospital.

We also adjusted the team for optimal performance. At first we had three sets of individuals showing up to a Code Strong (combative patient code). That included (1) the people who were there to help, (2) the people who were there for ‘muscle’, and (3) the people who wanted to see the muscle at work. This show of force created by convening every “able-bodied male” did not work well, and having 20 people standing around one agitated patient further intimidated the combative person.

STRATEGY FOR A STRIKE TEAM

We eventually developed a strategy for a strike team that consisted of Security, ED, and behavioral health personnel. The team was mostly comprised of no more than 5-7 people. When the team worked together, we quickly identified when someone was not able to successfully defuse the situation. We were able to easily place the next person into the lead role to develop a positive connection with the combative person. It was almost like watching art unfolding as this occurred – seeing the picture become clearer with every decision. It was also reassuring to know that the team behind you would identify a replacement for you who might be more effective based on the situation.

As we all know, promises cannot be made in these situations since it may lead the person to mentally leverage the negotiator to give him more – which can escalate the situation. Having the patience to work with the individual, talk to him, and reason with him, is often the best way to contain the situation.

CONVINCING A COMBATIVE BEHAVIORAL HEALTH PATIENT

An example of this was a situation involving a behavioral health patient who required medication. When we arrived on the scene, we were told that the patient was not cooperative and that we needed to go hands-on to get him to the quiet room. The trained security staff lead started talking to the patient without touching him, while walking in the direction of the quiet room. The officer talked about things unrelated to the situation like asking questions about the weather, what sports he liked, and other things that got his mind off of the situation. He continued calmly moving the patient toward the quiet room through conversation and walking beside him.

Once he reached the room, the patient became agitated that he was being medicated and became combative again. Security officers remained calm and quietly reasoned with him by asking him why he did not want to cooperate. He explained that he just wanted to look out the window one last time before he would not be able to remember it. We took him to the window in the quiet room and let him look out. After about 30 seconds, we told him that he needed him to cooperate with treatment and he agreed without further resistance.

COLLABORATION PLUS RESPECT FOR THE PATIENT

The bottom line and important lesson learned is that working with behavioral health and ED staff collaboratively is essential in defusing situations with combative patients. It’s important to develop a cohesive team and detailed training with the team for optimal performance. It is the best way to take advantage of resources to help manage patient issues in the hospital setting or elsewhere.

If you are willing to offer personal respect and patience to a combative patient, it will go a long way in helping manage a volatile situation. It will also limit your liability of potential harm to patients and staff. Today’s healthcare environment requires world-class customer service and service recovery that focuses on the best possible outcomes for patients, staff, and everyone involved.

Collaboration and patience are often the best way to handle patients.

(Timothy Quist is employed through ODS Healthcare Security Solutions Division as the Corporate Director of Security Services for INOVA Health System. He has extensive experience in crisis intervention, emergency management and preparedness, and disaster planning/recovery. He is also certified in Homeland Security Exercise and Evaluation Programs. He is a member of IAHSS.)