lunes, 18 de julio de 2016

Strategies To De-escalate Aggressive Behavior in Psychiatric Patients - Executive Summary | AHRQ Effective Health Care Program

Strategies To De-escalate Aggressive Behavior in Psychiatric Patients - Executive Summary | AHRQ Effective Health Care Program

AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Executive Summary – Jul. 14, 2016

Strategies To De-escalate Aggressive Behavior in Psychiatric Patients


Table of Contents


Aggressive Behavior

Aggressive behavior connotes using actual physical violence toward self, others, or property or making specific imminent verbal threats.1 In health care settings, approaches for actively aggressive patients have historically involved using either seclusion (involuntary placement of a patient in a locked room or area from which the patient is not allowed to leave) or restraints (involuntary administration of mechanical, pharmacologic, or physical interventions, which is seen as more restrictive than seclusion); these practices continue today.2,3 Since the late 1990s, the U.S. Centers for Medicaid & Medicare Services (CMS3) and the Joint Commission (www.jointcommission.orgExit Disclaimer) have required using seclusion and restraints only for a behavior that "jeopardizes the immediate physical safety of the patient, a staff member, or others"5 (including other patients) and when less restrictive measures have failed. Despite practice guidelines advocating limitations of seclusion or restraints as much as possible,6 data in the United States and Europe show that 10 percent to 30 percent of patients (adolescents, adults, and elderly persons) admitted to acute psychiatric units receive these interventions.7-9
Deciding to use seclusion or restraints raises several significant clinical or policy issues. First is how to best balance the benefits and risks of seclusion or restraints with those of various alternatives to those practices.7Second, whether an evidence base even exists to support using seclusion or restraints is debatable.7,10-13 Third, usual care, often represented in comparative studies as whatever was done before a new intervention was tried, varies substantially. Most guidelines and standards from regulatory agencies and accrediting bodies now recommend using seclusion and restraints only as a last resort.14-22 Finally, using seclusion and restraints is closely followed as a quality-of-care measure, particularly for psychiatric patients in hospital settings.23

Treatment Strategies

Much interest now focuses on using alternatives to seclusion and restraints. These strategies can address preventing aggressive behavior or reducing aggressive behavior once it has already developed (or both). Most alternatives are strongly influenced by the National Association of State Mental Health Program Directors' Six Core Strategies.24 These Six Core Strategies ultimately aim to forestall or at least decrease aggressive behavior.
Preventing aggressive behavior
Preventive strategies can be either general, multicomponent interventions that apply to all individuals (whether or not they are aggressive) or specific procedures aimed at persons who are at especially high risk of becoming aggressive. General preventive strategies emphasize providing a calm environment in which aggression is less likely to develop and tend to focus on entire care units. They include the following: risk assessment;25 milieu-based changes such as sensory rooms, which provide a calm and supportive environment for patients;26 staffing changes, such as increased staff-to-patient ratios;17 specific staff training programs;27 and peer-based interventions.28 Specific preventive strategies often try to intercede at the point of agitation, which is seen as a risk factor for becoming aggressive. These techniques can involve supportive (often referred to as nonconfrontational) language and other verbal de-escalation techniques, cognitive behavioral techniques, pharmacologic intervention treating the underlying psychiatric illness, and recognition of triggers for aggressive behavior. These two preventive approaches can overlap; specific strategies may also be applied as a general approach on a unit-wide basis.
Managing acute aggression
If patients do become actively aggressive, clinicians can use either seclusion or restraints or alternative strategies. In such cases, alternatives can include emergency response teams; these encompass behavioral emergency response teams,29 rapid response teams,29 and psychiatric emergency response teams.30 In addition, clinicians can employ pharmacologic interventions to reduce agitation quickly (rather than more gradually treating the underlying illness).

Scope and Key Questions

Scope of the Review

This small systematic review addresses interventions to prevent or de-escalate aggressive behavior and to reduce use of seclusion and restraint for aggressive behaviors. We focus on studies in acute health care settings, as to our knowledge no such review has been done using data from such settings. We are concerned with (1) the effectiveness of different available alternative strategies to prevent aggressive behavior and with (2) the effectiveness of alternative strategies compared with each other or with seclusion and restraints to de-escalate aggressive behaviors or improve health outcomes for those who are acutely aggressive. We conceptualize "de-escalate" in terms of both preventing aggressive behaviors and reducing use of seclusion and restraints.
We do not assess the accuracy of available risk assessment tools (a crucial step in the process of reducing aggressive behavior) or consider chronic care settings; although these are important considerations, they are beyond the scope of this review.

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