De-escalation strategies for dealing with the agitated patient was held at www.developingem.com conference at Salvador de Bahia 2014.

1. De-escalation
De-Escalation Strategies
for Dealing
with the Agitated Patient
Joachim Unger, MD
Germany

2. Aggressive behavior against
health care providors
Why

3. Aggression in
Prehospital Care/ ED
Acute Pain
Intoxication
Limited informations
Waiting time

4. Kinds of
Aggression
Instrumental-
premeditated-controlled-
planned-proactive-cold
blooded-hidden-
predatory-
postitve/constructive
Emotional-
hostile-impulsive-
uncontrolled-
unplanned-reactive-
hotblooded-overt-
affective-
negative/destructive

5. Aggression in Health Care: Escalated Interaction
Escalation
Conflict
Anger/Fear
Adversive
StimulationEmpathy/
Theory of Mind
Violence
Social System
Interaction
Mental System
ExpectationRole

6. NOW-modell

7. Elements of
violente situations
trigger – weapons – target – level of arousal

8. Key
Components
MANAGEMEN
T
Yourself
Maintaining
personal control
situational awareness
strategies for de-escalation
(when/where/how)
Communications
Verbal and non-
verbal skills
Structure
(environment)
safe conditions

9. Basic Strategies
Empathy
Early Intervention
Only one communicator
Assessment of emotional state

10. Characteristics
of effective
De-escalators
Open - Coherent -
Confident Concern for the

11. Maintaining
Personal Control
Appearing calm
Avoiding personal feelings
Supressing feelings of anger

12. .
Identifying the
Escalated Patient
High
piched
voice
Excessiv
e
Sweating
Shaking

13. Non-Verbal
De-Escalation
Keep an alert
postureNeutral facial
expression
Never turn your back for any reason
Limit eye
contact

14. Verbal
De-
Escalation
Do not get loud
Be honest
Be respectful
Respond
selectively

15. Strategies
Find out
the reason
Give guidance
Autonomy confirming vs.
Authorative Interventions
Establish rapport
Assessment of emotional state

16. Autonomy confirming
Interventions
Find aggreements
List consequences
Suggest alternatives
Empathize with feelings
Do not try to argue/ convince

17. De-Escalating
Aggressive
Behaviour1. Valuing the patient
2. Reducing fear
3. Enquiring about patient’s queries and anxiety
4. Providing guidance to the patient
4. Working out possible agreements
6. Remaining calm
7. Crosscheck: Take no risk
…brings the level of arousal down
to a safer place

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ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector.
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South Africa, Thailand, plus an additional Australian study: Synthesis Report. Geneva: ILO/ICN/WHO/PSI Joint
Programme on Workplace Violence in the Health Sector, forthcoming working paper.
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Centre for Clinical Practice
Review of Clinical Guideline (CG) 25: Violence: The short-term management of disturbed/violent behaviour in in-
patient psychiatric settings and emergency departments
NAU J. Et al. (2009) The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal
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RAMIREZ, J.M. Et al. Aggression, and some other psychological constructs (Anger, Hostility, and Impulsivity).
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Price O., Baker J. Key components of de-escalation techniques: A thematic synthesis International Journal of
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