Implementing Verbal De-escalation on Agitated Patients with Serious Mental Illness In a Community Healthcare Setting

Background: According to the National Alliance on Mental Illness [NAMI, n.d.], 43.8 million adults in the U.S. experience mental illness each year. Individuals with mental illness are not necessarily more aggressive or violent than people without mental illness. Substance abuse, adverse childhood experiences, lack of education, and homelessness have more robust correlations with patient aggression and violent behavior than serious mental illness. Behavioral health staff's use of confrontational posturing techniques coupled with demanding verbal directives has been shown to increase the risk of harm to patients and staff. Verbal de-escalation practices have been shown to reduce patient agitation and mitigate patient-staff altercations by lowering patients' anxiety, anger, and or fear states. Methods: This quality improvement project was conducted at an outpatient behavioral health clinic in Salt Lake City, serving individuals with serious mental illnesses. Participants were ten (n = 10) mental health clinicians who comprised the clinic's Assertive Community Treatment (ACT) team. Two surveys (pre-and post-) were developed and disseminated to evaluate the team's knowledge and comfort level implementing de-escalation techniques with aggressive or violent patients experiencing acute stress. An in-service presentation and toolkit were created to educate the ACT team in using verbal de-escalation techniques designed to promote emotional and behavioral stability in escalated patients and reduce the use of law enforcement personnel to manage patient behavior. Four weeks post-presentation training and toolkit dissemination, a follow-up survey was administered to the ACT team (n=10) to evaluate the efficacy of the training in terms of (a) reducing patient escalation incidences requiring law enforcement intervention, (b) identifying changes in the ACT team clinical practice, and (c) identifying changes in patients' behavior. Results: Pre-project intervention, 30% of patients (n = 30) exhibited weekly escalation behavior. Post-project intervention, 8% of patients (n = 8) exhibited weekly escalation behavior. The ACT team reported heightened awareness of patient escalation warning signs and increased confidence in using verbal de-escalation techniques to manage patient escalation behavior. Conclusion: Provision of verbal de-escalation training increases behavioral health care confidence in assessing and mitigating patient escalation behaviors. Increased comfort came from improvement in assessment skills and changing team dynamics by establishing groups of two or more when approaching an agitated patient, thereby decreasing the chance for patient violence. The downward trend in patient escalation is promising, with an average of 30% escalating initially to less than 10% events per week. These results suggest that the educational training and toolkit could benefit other community clinics serving patients with serious mental illnesses who may become agitated and violent in a crisis.