Staff behaviors in psychiatric and substance abuse treatment should be aimed at creating a safe milieu and promoting a positive culture. Skills critical to maintaining a safe environment center on awareness, attending, caring, and connecting.
Cardio Pulmonary Resuscitation
There is no substitute for taking a full cardiopulmonary resuscitation (CPR) course, but emergencies don’t wait for training. This course will instruct you on the basic guidelines endorsed by the American Heart Association. It is strongly recommended that you take a certification course in CPR. This can be achieved through www.onlineAHA.org.
CPR should be started as soon as possible.
1. Attempt to wake victim. If the victim is not breathing (or is just gasping for breath), call 911 immediately and go to step 2. If someone else is there to help, one of you call 911 while the other moves on to step 2.
If the victim is breathing, see the Tips section for what to do.
2. Begin chest compressions. If the victim is not breathing, place the heel of your hand in the middle of his chest. Put your other hand on top of the first with your fingers interlaced. Compress the chest at least 2 inches (4-5 cm). Allow the chest to completely recoil before the next compression. Compress the chest at a rate of at least 100 pushes per minute. Perform 30 compressions at this rate (should take you about 18 seconds).
It’s normal to feel pops and snaps when you first begin chest compressions – DON’T STOP! You’re not going to make the victim worse.
3. Begin rescue breathing. After 30 compressions, open the victim’s airway using the head-tilt, chin-lift method. Pinch the victim’s nose and make a seal over the victim’s mouth with yours. Use a CPR mask if available. Give the victim a breath big enough to make the chest rise. Let the chest fall, then repeat the rescue breath once more. If the chest doesn’t rise on the first breath, reposition the head and try again. Whether it works on the second try or not, go to step 4.
If you don’t feel comfortable with this step, just continue to do chest compressions at a rate of at least 100/minute.
4. Repeat chest compressions. Do 30 more chest compressions just like you did the first time.
5. Repeat rescue breaths. Give 2 more breaths just like you did in step 3 (unless you’re skipping the rescue breaths).
Keep going. Repeat steps 4 and 5 for about two minutes (about 5 cycles of 30 compressions and 2 rescue breaths).
6. If you have access to an automated external defibrillator (AED), continue to do CPR until you can attach it to the victim and turn it on. If you saw the victim collapse, put the AED on right away. If not, attach it after approximately one minute of CPR (chest compressions and rescue breaths).
After 2 minutes of chest compressions and rescue breaths, stop compressions and recheck victim for breathing. If the victim is still not breathing, continue CPR starting with chest compressions.
Repeat the process, checking for breathing every 2 minutes (5 cycles or so), until help arrives. If the victim wakes up, you can stop CPR.
CONTINUE WITH 30 PUMPS AND 2 BREATHS UNTIL HELP ARRIVES
NOTE: This ratio is the same for one-person & two-person CPR. In two-person CPR the person pumping the chest stops while the other gives mouth-to-mouth breathing.
1. Chest compressions are extremely important. If you are not comfortable giving rescue breaths, still perform chest compressions! It’s called Hands Only CPR.
2. If the victim is breathing put them in the recovery position laying on their side. If they are breathing but it is not stable breathing give them rescue breaths by plugging their nose and blowing in their mouth at a rate of 1 breath every 6-8 seconds. If their breathing does not become stable within two minutes begin CPR.
3. For CPR on children or infants the compressions should be kept at approximately 1/3 the depth of the chest. Be sure to start CPR as quickly as possible even delaying calling 911 if alone until after approximately 2 minutes of CPR. Be careful not to over expand the lungs of an infant when giving breaths.
This is not a substitute for actual CPR training. Find a CPR class and get proper training.
FIRST AID: What Is My Responsibility?
You have a duty to give the level of care that you will learn in this first aid course. Your have a responsibility to act the way a reasonable person with your level of training would act. No one expects you to give the level of care given by a professional such as an EMS rescuer, a nurse, a physician, or other healthcare worker.
A person who is ill or injured has the right to refuse care. If the victim is responsive, introduce yourself before you touch him/her.
- If the victim agrees, you may give first aid.
- If the victim refuses your help, phone 911 and stay with the victim until medical rescuers arrive.
- If the victim is confused or cannot answer, assume that he/she would want you to help.
As you approach the scene, you should think about the following:
- Is there any danger for the rescuer?
- Is there any danger for the victim?
- Are there other people around who can help?
- How many people are injured?
- Where is the nearest telephone?
- What is your location?
- Will you need protective equipment?
- Protective gloves
- Eye Protection
- Face Mask or Face Shield
- Biohazard Waste Bag
- Wash hands with soap and water
>How to remove protective gloves
When to Phone for Help:
You should phone the emergency response number or 911 and ask for help whenever someone is seriously ill or hurt or whenever you are not sure what to do.
If others are present it is better to ask them to phone the emergency number and bring the First Aid kit while you give first aid to the victim.
If you are alone, shout for help while you begin to give first aid. If no one answers your shout, leave the victim to phone 911. Phone for help, get the First Aid kit, and return to the victim.
A truck has struck an employee in the parking lot. You see a man lying on the ground. Several co-workers have gathered around him. You note that traffic is moving slowly around the crash.
After you have made sure the area is safe, you have to find out what the problem is before you give first aid. Learn to look for problems in a certain order.
1. When you arrive at the scene, be sure it is safe to go to the victim. As you walk towards the victim, try to look for signs of the cause of the problem.
2. Check whether the victim is responsive. Shake the victim gently and shout, “Are you OK?”
- A victim who is responsive will respond in some way.
- A victim who is unresponsive does not move or react in any way when you shake him/her.
3. Next, look to see if the victim is breathing normally.
- With a victim who is responsive you can just look to see if their breathing is normal.
- With a victim who is unresponsive you have to open the airway before you can check whether the victim is breathing.
4. Next, look for any obvious bleeding.
5. Look for a medical information bracelet or necklace. It will tell you if the victim has a serious medical condition.
FIRST AID: Medical Emergencies?
Chest Pain and Heart Attack:
Signs of a heart attack may include:
- An uncontrollable feeling in the center of the chest that lasts for more than a few minutes or that comes and goes
- An uncomfortable feeling in other areas of the upper body, such as one or both arms, the jaw, back, neck or stomach
- Shortness of breath
- Other signs, such as a cold sweat, nausea or lightheadedness
Signs of a Heart Attack in Women, the Elderly and People with Diabetes are often less clear.
>If you suspect a heart attack, phone 911
1. Have the victim sit quietly.
2. Phone or have someone phone your company’s emergency response number
3. Ask someone to get the AED, if available and a First Aid Kit.
4. Be ready to do CPR and use the AED if the victim becomes unresponsive.
Fainting is a short period of unresponsiveness. Before becoming unresponsive the victim feels dizzy. The unresponsiveness lasts less than a minute, and then the victim seems fine.
Fainting often occurs when the victim:
- stands without after squatting or bending down
- receives bad news
If a person is dizzy but is still responsive:
1. Make sure the area is safe.
2. Help the victim lie flat on the floor.
If a person faints and then becomes responsive:
1. Ask the victim to lie flat on the floor until all dizziness goes away.
2. If the victim remains dizzy, raise the victim’s legs about 12 inches and keep
them elevated until the victim is no longer dizzy.
3. Look for injuries caused by the victim’s fall.
4. Once the victim is no longer dizzy, help the victim to sit up very slowly and
briefly remain sitting before slowly getting up.
Diabetes and Low Blood Sugar:
Low blood sugar can occur if a person with diabetes
- has not eaten
- has not eaten enough food for the level of activity
- has injected too much insulin
Signs of low blood sugar can appear quickly and may include:
- a change in behavior, such as confusion or irritability
- sleepiness or even unresponsiveness
- hunger, thirst or weakness
- sweating, pale skin color
- a seizure
If the victim can swallow:
1. Give the victim something containing sugar to eat or drink
2. Have the victim sit quietly or lie down.
3. Phone or have someone phone 911
If the victim is unresponsive:
1. Phone or have someone phone 911.
2. Do not give the victim anything to eat or drink.
3. Do CPR as needed
Strokes occur when blood flow to a part of the brain is suddenly blocked. This can happen if a blood vessel in the brain is blocked or bursts. The signs of a stroke are usually very sudden.
1. Make sure the area is safe so that the victim does not get hurt.
2. Phone or ask someone to phone 911.
3. If the victim is unresponsive, do CPR as needed.
During a seizure the victim loses muscle control and may become unresponsive. The victim usually has jerking movements of the arms and legs and sometimes of other parts of the body.
1. Protect the victims from injury from injury by:
- moving furniture or other objects out of the victim’s way
- placing a pad or towel under the victim’s head
2. Phone or have someone phone 911.
*Do not hold the victim down
*Do not put anything in the victim’s mouth
FIRST AID: Injury Emergencies?
Bleeding You Can See:
>You can stop most bleeding with pressure.
>Bleeding often looks a lot worse than it is.
Take the following actions to stop bleeding that you can see:
1. Make sure that the area is safe for you and the victim.
2. Send someone to get the First Aid Kit.
3. Wear personal protective equipment.
4. If the victim is able, ask the victim to put pressure over the wound with a large
clean dressing while you put on gloves and eye shield.
5. You should be able to stop most bleeding with pressure alone. Put pressure
on the dressing over the bleeding area with the flat part of your fingers or the
palm or your hand.
6. If the bleeding is from a wound on an arm or leg, raise the arm or leg so that it
is higher than the chest while you continue to put pressure on the wound. Do
not raise the arm or leg if movement causes the victim pain.
*Do not remove penetrating objects
*When trying to stop a nosebleed do not ask the victim to lean his/her head back.
*When trying to stop a nosebleed do not use an icepack on the nose or forehead.
Shock and Bleeding You Can’t See:
Shock develops when thee is not enough blood flowing to the cell of the body.
Feels cold and shiver
Feels week, faint or dizzy
Is restless, agitated, or confused
1. Be sure the area is safe for the victim.
2. Phone or ask someone to phone 911.
3. Help the victim lie on his/her back.
4. If there is no leg injury or pain, raise the victim’s legs about 12 inches.
5. Use pressure to stop bleeding you can see.
6. Cover the victim with a blanket to keep the victim warm.
Bleeding you Can’t See:
A forceful blow to the chest or abdomen can injure the heart, lungs, liver and other organs. It can cause bleeding inside the body. You may not see signs of this bleeding on the outside of the body at all, or you may see a bruise of the skin over the injured part of the body.
1. Make sure the area is safe for you and the victim.
2. Phone or ask someone to phone 911.
3. Keep the victim still and lying down.
4. Check for signs of shock and give first aid as needed.
5. If the victim becomes unresponsive, send someone to get the AED and begin
Head and Spine Injury:
The brain is very likely to be injured whenever a victim has a blow to the head. The spine protects the spinal cord. An injury to this may make it impossible for the victim to move.
1. Make sure that the area is safe for you and the victim.
2. Phone or ask someone to phone 911.
3. Do not allow the victim’s head or neck to move in any direction.
Injuries to Bones, Joints and Muscles
1. Make sure that the area is safe for you and the victim and get the First
2. Cover an open wound with a clean dressing.
3. Check for signs of shock and give first aid as needed.
4. Don’t try to straighten any injured part that is bent.
5. Put a plastic bag filled with ice on the injured area with a towel between the
ice bag and the skin.
6. Wrap an elastic bandage around an injured joint.
7. Phone or ask someone to phone 911 if there is:
a large open wound
the injured part is abnormally bent
you’re not sure what to do
8. The victim should not walk on an injured foot or leg until checked by a
Heat burns can be caused by contact with fire, a hot surface, a hot liquid or steam.
1. Make sure the area is safe for you and the victim and get the First Aid Kit.
2. If the victim’s clothing is on fire, have the victim “stop, drop and roll”. Cover
the victim with a blanket and soak with water. Once the fire is out, remove
burned clothing and jewelry from the burned area if they are not stuck to the
3. If the victim is unresponsive, begin CPR as needed.
4. If the burn area is small, cool it immediately with cold, but not ice cold, water.
5. You may cover the burn with a dry, non-sticking sterile or clean dressing.
6. Phone or ask someone to phone 911 if:
- there is a fire
- a victim has a large burn
- your are not sure what to do
FIRST AID: Environmental Emergencies?
Bites and Stings:
Human and animal bites can be painful. When the bite punctures the skin, the wound can bleed and become infected.
1. Make sure the area is safe for you and the victim.
2. Phone or ask someone to phone 911 and get the First Aid Kit.
3. Clean the victim’s wound with soap (if available) and water under
pressure from a faucet.
4. Stop the bleeding by applying direct pressure.
5. Report all animal bites to the police or an animal control officer.
Non poisonous Snakes:
I_ _ _ _I
/ usually about 1/2 an inch apart, sometimes only one puncture wound
1. Back away from the snake or go around it.
2. Phone or ask someone to phone 911.
3. Ask the victim to be still and calm.
4. Gently wash the victim’s bite area with soap and water (if available).
5. If the bite was caused by a coral snake, apply mild pressure by wrapping several elastic bandages over the bite and the entire arm or leg.
DO NOT wrap the bite area with a dressing if any other snake causes the bite.
Frostbite affects parts of the body that are exposed to cold weather. Hypothermia occurs when body temperature falls. Heat related emergencies result from exposure to extreme heat.
Signs of Frostbite:
- The skin over the frostbitten area is white, waxy or grayish-yellow.
- The area is cold and numb.
- The area is hard and the skin doesn’t move when you push it.
1. move the victim to a warm place
2. Phone or ask someone to phone 911 and get the First Aid Kit.
3. Remove tight clothing, rings or bracelets from the frostbitten area
4. Remove any wet clothing.
5. Do not try to thaw the frozen part if you are close to a medical facility or if
there is a chance of refreezing.
Signs of Hypothermia:
Shivering is present in mild hypothermia but stops when the hypothermia becomes severe.
Confusion or a change in personality
Muscles become stiff and rigid and the skin gets ice cold and blue
The victim becomes unresponsive.
1. Get the victim out of the cold.
2. Keep the victim lying flat.
3. Replace wet clothing with dry clothing.
4. Phone or ask someone to phone 911.
5. Put blankets under and around the victim. Cover the victim’s head, but not their face.
6. If the victim is unresponsive, begin CPR.
Signs of Heat Related Emergencies:
- Muscle cramps
Signs of Heatstroke:
- Confusion or strange behavior
- Inability to drink or vomiting
- Red, hot and dry skin
- Shallow breathing, seizures or unresponsiveness
- Move the victim to a cool or shady area.
- Loosen or remove tight clothing.
- Encourage the victim to drink water.
- Sponge or spray the victim with cool water and fan the victim.
- Phone or ask someone to phone 911 if there are any signs of heatstroke and continue to cool the victim until rescuers arrive.
- If the victim becomes unresponsive, phone 911 and start CPR as needed.
A poison is anything someone swallows, breathes or gets in the eyes or on the skin that causes sickness or death.
1. Phone or ask someone to phone 911 and get the First Aid Kit.
2. Make sure the area is safe before you approach the victim. If the area seems unsafe, do not enter. Tell everyone to move away from the area.
3. Try to move the victim from the area of the poison if you can do safely.
4. If a victim is unresponsive, begin CPR, but do not perform mouth to mouth breathing if the poison has contaminated the victim’s lips or mouth.
5. Wash or remove the poison from the victim’s skin and clothing if you can do so safely.
6. If you can identify the poison send someone to get the MSDS.
7. When you know the name of the poison, call the nearest poison center for instructions on giving first aid.
POISON CONTROL: 1-800-222-1222
Universal precautions is an approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other bloodborne pathogens. Utilizing these techniques will help to protect the responder, as well as other potential victims through reducing the spread of infections.
–wash hands before and after each medical procedure (may use a waterless hand cleaner)
-wear gloves whenever there is a possibility of coming in contact with blood or other potentially infectious materials (body fluids and tissues)
-wear full-body gowns whenever there is a possibility of blood splashing onto the rescuer
-wear face masks and eye protection whenever there is a possibility of blood splashing into the rescuer’s face
-dispose of all contaminated sharp objects in an appropriate puncture-proof container
-dispose of all contaminated personal protective equipment in an appropriate container marked for bio-hazardous waste
Lay rescuers should consider following universal precautions as much as possible. To adequately follow universal precautions, a rescuer must have appropriate personal protective equipment available. Make sure first aid kits contain – at a minimum:
-a CPR barrier
HIV and AIDS
The Human Immunodeficiency Virus, which is commonly referred to as HIV, is a virus that directly attacks certain human organs, such as the heart or kidneys, as well as the human immune system. The immune system is made up of cells, which work to protect the body from infections and some cancers. HIV attacks the cells, which are required for proper immune system function. When HIV destroys enough of these cells there is a failure of the immune system to protect the individual from certain opportunistic infections.
Acquired Immunodeficiency Syndrome, or AIDS refers to an individual who has very advanced HIV disease and their immune system has incurred significant damage.
According to The Centers for Disease Control the conditions that mark a progression from HIV disease to AIDS are:
Symptoms of HIV Infection
The only way to determine for sure whether someone has HIV/AIDS is to be tested for the HIV infection. Someone cannot rely on symptoms to know whether or not they are infected with HIV. Many people who are infected with HIV do not have any symptoms at all for many years. The potential symptoms include:
According to the Center for Disease Control (CDC) HIV continues to be on the rise. In the United States, AIDS has become the leading killer of adults in their prime working years. About 1.4 million people in the U.S. are currently infected with HIV or have AIDS. In the United States, women, young people and minorities, in general, are now the most likely to contract HIV.
Advances in HIV have led to dramatic declines in AIDS deaths and slowed the progression from HIV to AIDS. Better treatments have led to a rise in the number of people in the United States who are living with AIDS. This growing population represents an increasing need for better understanding, empathy, support, continued HIV prevention services and treatment.
The latest statistics on the world epidemic of AIDS & HIV were published by UNAIDS/WHO in November 2006, and refer to the end of 2006.
People living with HIV/AIDS in 2006
Adults living with HIV/AIDS in 2006
Women living with HIV/AIDS in 2006
Children living with HIV/AIDS in 2006
People newly infected with HIV in 2006
Adults newly infected with HIV in 2006
Children newly infected with HIV in 2006
AIDS deaths in 2006
Adult AIDS deaths in 2006
Child AIDS deaths in 2006
More than 25 million people have died of AIDS since 1981. At the end of 2006, women accounted for 48% of all adults living with HIV worldwide, and for 59% in sub-Saharan Africa. Young people (under 25 years old) account for half of all new HIV infections worldwide – around 6,000 become infected with HIV every day.
While there are treatments that help people survive some of the diseases they get as a result of losing their immunity, there is no cure for AIDS. Although scientists have yet to find a cure or an effective vaccine, AIDS, unlike many other life-threatening illnesses, is completely preventable. We have knowledge, technology and resources to halt the spread of the epidemic. We know how HIV is and is not spread. Educating everyone about how to protect him or herself is the only way we can halt the spread of this disease. Prevent HIV infection and you will prevent AIDS.
Medical tests detect antibodies to HIV. These antibodies are in the bloodstream, and are an attempt of the immune system to eliminate the virus. Antibodies are generally detectable 6 to 12 weeks after infection with HIV. When antibodies are present in someones blood, that person is said to be HIV-positive. Generally, in an untreated HIV-infected person, symptoms serious enough to constitute an AIDS diagnosis begin to appear eight to ten years after infection.
Before highly active antiretroviral therapy became available, most people who contracted HIV eventually progressed to AIDS and had some AIDS-related complication such as deterioration of the immune system functioning and an increased risk of infection and cancers. Presently, most HIV-positive people live normal, active lives for several years after infection.
A number of factors can affect how rapidly HIV progresses, some that can be controlled, and some that cant. An individual who takes better care of himself or herself, which improves the immune system, and following the doctors advice slows the progression of HIV disease to AIDS. An infection by a virulent strain of HIV, having a higher viral load, older age, and the abuse of alcohol and other drugs may cause the HIV progression to AIDS to be more rapid.
As we continue to research how to control and eventually eradicate this disease, our efforts have focused on the identification of the ways in which HIV can be transmitted.
The Centers for Disease Control and Prevention (CDC) report the following facts concerning the transmission of HIV.
The first step in controlling HIV is to prevent new infections.
There are three key things that can be done to help prevent all forms of HIV transmission. Promoting widespread awareness of HIV and how it can be spread; counselling and testing, and providing antiretroviral treatment. This treatment enables people living with HIV to enjoy longer, healthier lives, and as such it acts as an incentive for people to volunteer for HIV testing. It also brings people into contact with health care workers who can deliver prevention messages and interventions.
Out of these three key components we will look at specific protocols and recommendations based on the route of transmission.
Prevention of Occupational Exposure
There are many strategies that can be used to reduce the risk of occupational exposure.
- The primary means of preventing the health care worker’s occupational exposure to HIV and other blood-borne pathogens is to follow infection control precautions with the assumption that the blood and other body fluids from all patients are potentially infectious. These precautions include
o routinely using barriers (such as gloves and/or goggles) when anticipating contact with blood or body fluids
o immediately washing hands and other skin surfaces after contact with blood or body fluids
o carefully handling and disposing of sharp instruments during and after use.
- Safety devices also have been developed to help prevent needle-stick injuries.
If used properly, these types of devices may reduce the occupational HIV exposure risk. Furthermore, because many percutaneous injuries are related to sharps disposal, strategies for safer disposal, including safer design of disposal containers and placement of containers, are being developed.
- Although the most important strategy for reducing the risk of occupational HIV transmission is to prevent occupational exposures, plans for post exposure management of health care workers should be in place. The administration of antiretroviral drugs as post exposure prophylaxis (PEP) should be considered. Using zidovudine as PEP has been shown to be safe and associated with decreased risk for occupationally related HIV infection. Newer antiretrovirals also may be effective, although there is less experience with their use as PEP. CDC recently issued guidelines for the management of HCW exposures to HIV and recommendations for PEP. These guidelines outline a number of considerations in determining whether or not an HCW should receive PEP and in choosing the type of PEP regimen. The recommendations will be updated if ongoing data collection and analysis show increased effectiveness of newer drug treatments.
As mentioned, all health care workers should use universal precautions. These precautions should include the routine use of gloves and or goggles when contact with blood or body fluids is possible, washing hands and other skin surfaces immediately after contact with blood or body fluids and using extra care when handling or disposing of sharp instruments.
Precautions Regarding Sex
To reduce the transmission of HIV the CDC recommends abstinence, monogamy with a safe, tested significant person or at a minimum the use of latex or polyurethane condoms.
Injectable Drug Use
Abstinence from IV drug use is also a necessary component to the reduction in the transmission of HIV. If drug use is an issue, the user should only use clean needles and syringes and seek the aid of a substance abuse rehabilititation program.
Perinatal Transmission of HIV
The perinatal transmission of HIV each year in the United States by approximately 6,000 to 7,000 HIV-infected women giving birth, results in 280 to 370 new perinatal infections. Approximately 40% of the HIV infected women who pass their HIV to their child never knew they were HIV infected or were never tested for HIV during their pregnancy.
Effective prevention of mother-to-child transmission (PMTCT) requires a three-fold strategy.
- Preventing HIV infection among prospective parents
- Avoiding unwanted pregnancies among HIV positive women
- Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labour, delivery and breastfeeding
The last of these can be achieved by the use of antiretroviral drugs, safer feeding practices and other interventions
For HIV-positive women in well-resourced countries the advice from national health agencies is straightforward: they should avoid breastfeeding altogether because the risk of HIV transmission far outweighs the risks associated with replacement feeding.
Many women do not know that perinatal transmission of HIV is preventable. Only about 33% of all hospitals offer rapid HIV testing to women in labor and only 50% of them have policies to test women whose HIV status is unknown.
The strongest weapon against HIV is education. As a society and each individual must conquer the fear through knowledge and education rather than allowing the fear to post pone testing and take part in unsafe practices such as unprotected sex.
The Centers for Disease Control and Prevention has recommended that HIV testing and HIV screening be part of routine clinical care in all health care settings. The CDC also has stated it suggests that the patient’s right to refuse be preserved in order to facilitate a good working relationship between patient and doctor. The following summarizes the HIV testing recommendations from the CDC.
Patients in all Health-Care Settings
- HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
- Persons at high risk for HIV infection should be screened for HIV at least annually.
- Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient and imply consent for HIV testing.
- Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings.
- HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
- HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).
- Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient for HIV testing.
Repeat screening in the third trimester is recommended in certain areas with elevated rates of HIV infection among pregnant women.
Types of HIV Tests
There are 3 primary tests for HIV.
- Western Blot
- PCR (Viral Load)
The tests to determine if a person has been infected with HIV really do not test for the actual HIV virus. Instead, these tests detect proteins that circulate in the body when a person has been infected with HIV. Two of these antibody blood tests are used to detect HIV antibodies in the bloodstream while the third detects HIV proteins.
This is the first portion of the HIV test. This test detects the presence of HIV antibodies in the blood. If the test is negative then the person is determined not to be HIV infected. If the test is positive the second portion of test is run to confirm the results.
This test is used to confirm a positive Elisa test. The Western Blot test detects specific protein bands that are present in an HIV infected individual.
In combination with a positive Elisa, a positive Western Blot is 99.9% accurate in detecting HIV infection.
PCR detects specific DNA and RNA sequences that indicate the presence of HIV in the genetic structure of anyone HIV infected. After one is infected with HIV, RNA and DNA from the HIV virus circulates in the blood. The presence of these DNA and RNA “pieces” indicates the presence of HIV virus.
Getting tested earlier than 3 months may result in an unclear test result, as an infected person may not yet have developed antibodies to HIV. The time between infection and the development of antibodies is called the window period. Some test centers may recommend testing again at 6 months.
It is also important that an individual is not exposed to further risk of getting infected with HIV during the window period. The test is only accurate if there are no other exposures between the time of possible exposure to HIV and testing.
If an individual’s test is negative at six months and they have not had unprotected sex or shared needles again in the meantime, it means that they do not have HIV, and will not therefore go on to develop AIDS.
The importance of testing and diagnosis is ever increasing with significant progress being made regarding the treatment of HIV. Antiretroviral medications can slow and even stop the damage occurring to the body. Medical compliance is crucial to slowing the progression of HIV to AIDS.
The Initiation of Treatment
- Antiretroviral therapy is recommended for all patients with AIDS defining illnesses or symptomatic HIV infection regardless of CD4 count or HIV Viral Load.
- Antiretroviral therapy is recommended for asymptomatic patients with a CD4 count < 200.
- Those asymptomatic patients with CD4 counts of 201 – 350 should be offered treatment.
- Most experienced clinicians will defer treatment for those asymptomatic patients with CD4 counts > 350 and viral loads > 100,000.
- HIV Treatment should be deferred for those patients with a CD4 count > 350 and a viral load of < 100,000.
Under most circumstances, HIV testing is voluntary. Unless there are special circumstances, most states require a person to give informed consent before he or she can be tested for HIV. Many options are available for anonymous testing at clinics and at home. Most states have laws that protect the confidentiality of HIV testing and diagnosis.
Confidentiality is a complex issue. The need for confidentiality is paramount to further the efforts of testing and treatment. However, most if not all states carry the requirement of disclosing HIV status to a prospective sexual or needle-sharing partner. In some states, failure to do so is a misdemeanor; in others it is a felony. The challenge lies in defining an identifiable sexual or needle-sharing partner while respecting the rights of the HIV-infected individual to confidentiality.
Reporting HIV and AIDS in Florida
As part of informed consent, it is important to verbalize and put in writing your responsibilities as a professional prior to beginning assessments and treatment. Also, should a situation arise where you are unsure it is always best to seek supervision through a supervisor and mentor in your field.
HIV/AIDS cases should be reported to the local county health department within 2 weeks of diagnosis, per FL Statutes. Cases may be reported ONLY by MAIL or by TELEPHONE.
The Centers for Disease Control and Prevention (CDC) published its first surveillance case definition for Acquired Immune Deficiency Syndrome (AIDS) in September of 1982. Starting in 1983, Florida designated AIDS as a reportable disease and an AIDS surveillance program was instituted. Reporting at that time, however, was voluntary and it was not until 1986 that the mandatory reporting of AIDS became incorporated into Florida Statues (s.384, F.S.). Currently an HIV positive patient age 13 or older meets the CDC surveillance case definition of AIDS if they have a CD4 T-lymphocyte count less than 200/ul or 14%. They also meet the criteria if they have any one of 26 opportunistic infections. Florida Administrative Code 64D directs that all AIDS cases, as defined by CDC, be reported to the local county health department by physicians who diagnose or treat AIDS.
AIDS surveillance data has provided critical information necessary for tracking this disease and targeting both prevention and treatment resources. In recent years, however, AIDS surveillance data has been less reflective of the epidemic due to the success of antiretroviral therapy. Individuals infected with HIV are doing better and the progression from HIV to AIDS is much longer. People are living longer, healthier lives. Consequently, the number of AIDS cases has dropped. With fewer cases and longer progression from HIV to AIDS it is difficult to know where new infections are occurring and where to target resources.
In 1996 legislation was passed, amending s.384, F.S. and 64D, F.A.C., authorizing the Department of Health to establish rules to require both laboratory and physician reporting of positive HIV infections. Effective July 1, 1997 HIV infection became reportable by name in the State of Florida. Laboratories are required to report within 3 working days from the date of receipt of test results and physicians are required to report within 2 weeks of diagnosis. Only confidential positive tests which diagnose HIV infection are reportable. Examples of tests, previously noted, to diagnose HIV infection are anti-body-based testing systems such as repeat ELISAs followed by a Western Blot, and antigen tests such as p24 antigen or polymerase chain reaction (PCR), when these are used for confirmatory purposes. Tests to determine viral load are not reportable unless done to diagnose HIV infection. Under Florida Law there is no retroactive reporting; only positive results obtained from specimens collected on or after July 1, 1997 are reportable.
HIV reporting in the state of Florida was implemented, not only to have a more accurate picture of the epidemic, but also to link patients to services. Under Florida Law a health department representative will contact the reporting physician for permission to contact the patient. This contact is for the purpose of offering and initiating follow-up services. Examples of follow-up services are: post-test counseling for persons who did not return for test results, referral for medical evaluation, case management services, and voluntary partner notification. This linking of seropositive patients to services is one reason that patient names are necessary on the reports. Another reason names are needed is to prevent duplication. Eliminating duplicates prevents the inflation of statistics and ensures that the data are as accurate as possible.
For those patients not wishing to be reported if positive, Florida Law requires that anonymous testing be readily available in all counties of the state through the county health department. Persons who test positive for HIV through the anonymous testing system will not be reported. All persons being offered an HIV test are required by law to be informed about These locations are mandated by law to give equal opportunity to use or enjoy the public accommodation of goods, services, or facilities.
HIV/AIDS related illnesses are also covered under the Family & Medical Leave Act. This allows eligible employees to take off up to 12 work weeks in any 12 month period to care for themselves or a family member with a serious health condition.
Working with Patients with HIV/AIDS
The patient with HIV/AIDS is facing not only a life-threatening and often fatal illness, but also with the social stigma, public fear and concerns of transmitting the illness to loved ones. They often face isolation, discrimination, loss of career and in many circumstances abandonment by family and friends. They are financially threatened by medical expenses and fear for their benefits. In many situations they also are faced with the grief and loss from friends and loved ones who have died from AIDS. Medical professionals must address the psychological, biological and social aspects of this illness.
With the advances made in treatment, HIV-positive clients should not be treated as hospice patients. Many HIV-infected clients live normal lives for years to come. For this reason it is important to help the client to establish coping mechanisms for long term well being.
The treatment plan should address medical compliance and social services should develop a plan including issues relating to prejudice, support issues, concerns about relationships, depression, anxiety and suicide risk assessment and education.
Universal precautions should be used with HIV positive clients, just as they should be used with all patients.
HIV Positive Personnel
Twenty years ago, returning to work with HIV was not an issue. It was not an issue because people were too sick or died soon after their diagnosis. But today, with the advent of powerful HIV drugs, people are living long productive lives. People are feeling well and want to resume their normal lives…lives that include family, relationships, and employment. While going back to work is a positive thing, there are things you must know before returning to the workplace to avoid problems after taking the job.
Unless your HIV disease affects your ability to perform your job you are under no legal obligation to disclose your HIV status. And because HIV is not transmitted by casual contact, your HIV infection does not put any of your coworkers in danger of being infected.
Employers should proactively develop comprehensive personnel policies to address the broad-spectrum HIV-related issues that can arise at the work site. The ever-expanding scope of the HIV epidemic essentially guarantees that all employers will be confronted with the human relations issues related to HIV infection.
The “hands-on” nature of health care creates specific challenges in drafting scientifically sound personnel policies. While employment and personnel policies frequently reflect societal attitudes on a number of issues, health care employers must base HIV policies on scientific facts rather than misinformation and/or in response to political/social pressures.
Personnel policies should create a maximally safe and healthful environment for all workers.
Legal topics discuss HIV infection reporting and the availability/location of anonymous test sites. A list of anonymous test sites in your area can be obtained from your local county health department. However, once a person meets the CDC defined AIDS criteria they are reportable, regardless of whether or not they tested anonymously. Furthermore, because AIDS is still a reportable disease a new report needs to be filed for all HIV reported persons who later meet the AIDS criteria.
HIV & AIDS Reporting Guidelines
Legal Protection for the HIV-infected Person
The Americans with Disabilities Act (ADA) gives federal civil rights protection to individuals who are diagnosed with HIV/AIDS. Persons with HIV, both symptomatic and asymptomatic are protected by law against discrimination and are entitled to equal opportunity in public accommodations, employment and transportation. Additionally, individuals who are discriminated against because they associate with an HIV-infected person are also protected by the ADA.
This protection prohibits all private employers with 15 or more employees, as well as all public entities, regardless of their size from discriminating in employment against qualified individuals with disabilities. This includes hiring, firing, as well as the job application procedures such as interviewing, job assignments, training, promotions, wages, benefits, leave and all other employment related activities. An example of this protection could include a hospital that discharged a mental health technician due to their HIV-positive status. Customer or co-worker attitudes do not constitute just cause for discharge.
The ADA mandates that an employer may not ask or require a job applicant to take a medical examination before making a job offer. It cannot make any pre-offer inquiry about a disability or the nature or severity of a disability. An employer may inquire as to whether a candidate is able to perform the duties of the job.
The ADA requires that medical information be kept confidential. Medical information must be kept in a separate file apart from an individuals personnel file. All licensing boards have very strict guidelines for the maintenance of client files. Most require that client files be maintained in a locked file cabinet in a locked room. Only authorized staff is allowed to review charts. Again, it is stressed that the policy for confidentiality is best clearly defined in the informed consent.
Public accommodation is also a legally protected issue. Public accommodation relates to a private entity that owns, operates, leases or leases to a place of public accommodation. This would include places such as restaurants, shopping malls, medical practices, as well as others.
Post Exposure to BBP
Although not a primary means of HIV transmission, occupational exposure to HIV has resulted documented cases of HIV seroconversion among health care workers in the United States.
Although as discussed in the prevention section of this course, preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired HIV infection, it is also appropriate to look at post exposure management as an important element of workplace safety.
If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a patient during the course of your work, immediately follow these steps:
- Wash needlesticks and cuts with soap and water
- Flush splashes to the nose, mouth, or skin with water
- Irrigate eyes with clean water, saline, or sterile irrigants
- Report the incident to your supervisor
- Immediately seek medical treatment
Any incident of exposure should be reported to your supervisor immediately.
De-escalating Aggressive Behavior
Every day counselors, nurses, psychiatric technicians and others are called upon to intervene in crisis situations which may become dangerous if not handled properly.
Staff members deserve comprehensive training that adequately prepares them for the realities of working with a potentially aggressive population. This is also crucial for the well-being and therapeutic benefit of the population, as well.
This course will explore crisis intervention techniques, which can include verbal de-escalation and physical interventions. Our focus will primarily be on positive and behavioral supports with a strong emphasis on prevention and verbal strategies rather than physical interventions. However, we will briefly explore restrictive measures such as seclusion, physical restraint, mechanical restraint and chemical restraint so that the learner will have been introduced to the concepts. Use of physical force with this population predictably leads to resistance, and resistance to restraint as well as potential harm to the patient and staff.
Effective aggression control is relationship centered. It is necessary to have an understanding of the source of the immediate problem, and then have the ability to use resources, relationships, rules and desired outcomes to manage behavior. Staff must vigilantly safeguard the patients physical and emotional safety by utilizing professional judgment and skills during times of stress, by being at their best when patients are their worst: in crisis.
In psychology, as well as other social and behavioral sciences, aggression, also called combativeness, refers to behavior between members of the same species that is intended to cause pain or harm. Frequently it is used to regain control when someone feels as though they have lost authority over their decisions or well-being.
Aggressive behavior may be a symptom of a number of DSM 5 psychiatric diagnoses, including conduct disorder, oppositional defiant disorder, behavior disorder not otherwise specified, intermittent explosive disorder, impulse control disorder not otherwise specified and some personality disorders, as well as can be seen throughout alcohol and other drug addictions. Thus, aggressive behavior may be related to a very wide range of diagnoses.
Aggression takes a variety of forms among people based upon culture, personality, psychosocial history, gender and situation. Aggression can be physical, mental, or verbal.
There are two broad categories of aggression. These include hostile, affective, or retaliatory aggression and instrumental, predatory, or goal-oriented aggression. Empirical research indicates that there is a critical difference between the two, both psychologically and physiologically.
Some research indicates that people with tendencies toward “affective” aggression, defined as being “impulsive, unplanned, overt, or uncontrolled” have lower IQ’s than those with tendencies toward “predatory” aggression, defined as being “goal-oriented, planned, hidden, or controlled”.
Culture is a distinctly human factor that plays a role in aggression. Empirical cross-cultural research has found differences in the level of aggression between cultures. In one study, American men resorted to physical aggression more readily than Japanese or Spanish men, whereas Japanese men preferred direct verbal conflict to their American and Spanish counterparts. Within American culture, southerners were shown to become more aroused and to respond more aggressively than northerners when affronted. There is also a higher homicide rate among young white southern men than among white northern men in the United States.
Behaviors like aggression can be learned by watching and imitating the behavior of others. A considerable amount of evidence suggests that watching violence on television increases the likelihood of short-term aggression in children.
Gender is a factor that plays a role in both human and animal aggression. Males are historically believed to be generally more physically aggressive than females.
Some studies have found that more males than females exhibit aggression. Further, aggressive behavior is exhibited more frequently or more intensely in adolescents and young adults. It usually declines in middle and later adult- hood. However, aggressive behavior is often very stable over time.
This is one of the most robust and reliable behavioral sex differences, and it has been found across many different age groups and cultures.
Aggression is more likely in persons with one or more of the following conditions:
Greater degrees of intellectual disability;
Organic brain damage
Difficulties in language;
Poor coping skills;
Poor problem-solving skills;
Poor social skills;
Poor social support;
Simultaneous psychiatric disorders.
With psychiatric and alcohol and other drug treatment populations you frequently have:
Fewer social skills
Multiple legal and social problems and
A history of substance abuse
Each of these can exacerbate a tendency toward aggressive behavior.
Warning Signs of Aggressive Behavior
Aggressive behavior and violence is a serious issue for psychiatric and alcohol and other drug treatment facilities. In most cases it is potentially predictable because of warning signs exhibited by patients. Often times, in research, it is shown that staff plays a very large part in the escalation or preferably the de-escalation of a crisis situation. It has been discovered that a relative lack of response by staff members to the violent acts of patients is of concern. It is very important for staff to be trained to identify warning signs and act accordingly to avoid an intensification of negative behavior.
Potential Triggers for Violent or Aggressive Behavior:
Significant loss or frustration (e.g. losing a pass or parental rights)
Receive a warning about their behavior
Believe they’ve been treated unfairly or disrespectfully
Fail to receive a privilege they expected or counted on
Have a hostile relationship with another client
Hear news (from courts or DCF) that they didn’t want to hear
Feel they have nothing to lose
- Poor peer relationships
- Poor personal hygiene
- Drastic changes in personality
- Making threats of violence, getting back at someone, etc.
- Intimidating others
- Getting very angry easily or often
- Using abusive language
- Believing others are out to get him or her
- Blaming others for their problems
- Being rigid and inflexible
Staff should avoid:
- Letting threats go
- Ignoring aggressive behavior or warnings signs of aggressive behavior
- Failure to report abnormal client behavior to other staff members
- Failure to follow established rules and procedures
- Treating clients deferentially (playing favorites)
- Treating clients disrespectfully
- Speaking in very loud or aggressive tones of voice
- Expressing their own frustration to a client inappropriately
- Ignoring client requests, frustrations or angry feelings
- Staff awareness of client behaviors, personalities and coping styles is key to identifying situations that could lead to aggression
Strategies for the Diffusion of Potentially Aggressive Situations
Anger management and stress reduction techniques are important components of prevention in psychiatric and alcohol and other drug treatment facilities and should be a component of a psycho-education program.
How staff treats clients who are angry and/or frustrated has a direct impact on the probability of aggressive or violent behaviors.
Helping to keep the unit or group a positive and peaceful place begins at intake with the assessment and collection of the history regarding aggressive behavior. This assessment will continue through the admission process, and be part of the psychiatric, nursing and social work assessments throughout treatment.
Intake staff, admission staff, and program staff should systematically communicate with patients and their families, when appropriate, about treatment goals, progress and that patients will be encouraged and expected to make every effort to manage their own behavior. When patients are a part of the treatment goals and have control over parts of their progress they are less threatened and frustrated by the loss of control of a program with rules and parameters.
The management of aggressive behavior continues after the intake and assessment with diagnosing and treating the underlying psychiatric illness and being aware of the propensity for aggressive behavior in certain situations. The evaluation of a patient should include a review of aggressive behavior, including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events that are associated with aggressive acts. Cultural factors may influence the triggers and expression of aggression by patients and the response to aggression by staff and these factors should be considered in treatment facilities. Cognitive limitations, neurological deficits and learning disabilities should be noted during the intake evaluations.
The treatment plan should include strategies to prevent aggressive behavior, de-escalate behavior before it escalates, and initiate or refer out to, when necessary, psychological treatments for treating the underlying psychopathology when present.
Patients with a history of aggressive behavior may benefit from anger management, problem-solving and psycho-educational programs.
Staff can help to prevent aggression by:
- Attending trainings
- Learning all policies and procedures
- Being aware of each clients history
- Following the rules and boundaries established by the program and facility
- Treating all clients fairly and with respect
Staff should always treat the patients with respect. Judgmental attitudes, authoritative directives will likely result in anger and shame, feelings that in turn can result in negative behaviors.
As mentioned previously, communication is crucial for effective treatment and for the patients compliance, as well. Staff members should explain who they are, what they are going to do and why it is necessary. Speak to the patients about their treatment and offer them choices wherever practical. Staff should frequently check with the patient or client about their level of comfort with the physical surroundings and so forth. If it is impossible to comply with a patients request, explain why.
Staff must always provide for the safety of all other patients, as well. As tensions rise, it is important to enlist the help of staff that are familiar with the patient, and have successfully redirected behavior(s) in the past.
Before aggression is apparent staff can verbally redirect and assist the patient to a quiet area of the facility that is free from all stimuli, and is away from other patients or residents. Time outs can be utilized for behaviors, which place others in potential danger. This can be offered as an opportunity for the patient to manage their emotions on their own rather than a directive as if from a parent to a child.
Positive reinforcement for a patient who successfully calms their potential aggression should be offered through comfort measures and words. Always document the effectiveness of interventions on the part of the staff and the individual.
Be Alert to Situations that could lead to aggressive behavior. The earlier staff intervenes, the easier it is to de-escalate a potentially dangerous situation.
Pain and discomfort increase aggression. Assess for signs of acute pain. If the cause of the behavior is believed to be pain related, perform a pain assessment and notify a physician as warranted for tests, treatments, or alterations to the current plan.
Alcohol impairs judgment, making people much less cautious than they usually are. It also disrupts the way information is processed. A drunk person is much more likely to view an accidental event as a purposeful one, and therefore act more aggressively. It is likely that similar impairment occurs during drug treatment, especially during the detox phase. This means that people in the early stages of recovery are more likely to misinterpret events and become angry or aggressive.
Tips to Avoid Aggression:
-Follow established policies and procedures
-Be alert for signals that a potentially violent persons problems are getting worse
-Don’t ignore troubling client behavior, statements, or attitudes
-Be aware of clients personal situations that could trigger an aggressive reaction
-Have another staff member present when you have to give bad news to a client if you’re concerned about possible violence
-Model calm and appropriate behavior for clients
-Be knowledgeable about warning signs for aggressive/violent behavior
-Treat all clients fairly
–Be aware of client histories, personalities and coping styles
-Pay attention during change of shift reports
–Watch clients behavior and affect
-Intervene as early as possible to prevent incidents from escalating
-Use common sense
-Make sure that movies/TV shows etc are appropriate for the therapeutic environment
-Speak in soft and calm tones when confronting a client
Crisis Intervention Techniques
Sometimes, even if staff members are able to identify warning signs and use appropriate de-escalation techniques violence and/or aggression occurs. In this situation it is important to employee crisis intervention techniques.
-Call other staff (who are on site) for assistance
Remove other patients from the area by sending them to another area of the facility
Scan the area for potential weapons such as chairs or large objects and if possible keep them away from the aggressive person.
Verbally attempt to calm the violent person down
Avoid becoming physical
Maintain a safe distance
Call 911 if needed
Use your agency’s established policy
Once a patient has become aggressive it is crucial to maintain composure, act swiftly to manage the situation and protect the patient, the other residents and the staff.
Keep in mind that it is important to:
-Return the feeling of control, as much as possible, to the individual acting out. They have a choice as to how this situation will play out. Allow them to be a part of the solution when possible.
-Help the patient determine self-capacities, strengths and resources.
When faced with an angry patient:
- Acknowledge an angry patients concerns,
- Allow the person to express their feelings
- Use non-confrontational language
- Maintain eye contact
- Avoid yelling or speaking loudly
- Let the patient know you are there to help
- Focus on acknowledging the feelings of the client
- Speak slowly and softly (use a calming voice)
- People read body language to decide how to act if you appear relaxed and in control of yourself the client is much more likely to calm down
- Move to solving the problem if at all possible
- Offer alternatives if at all possible
Here are a few phrases staff can use:
It seems like you’re upset about . . . is that right? Let’s see what we can do
It has to be frustrating to have to . . .
These utilize active listening skills. They help you ensure your understanding of the situation, get and give information, build trust and achieve what is necessary for the safety of everyone and possibly help to achieve what the patient wants or needs.
ACTIVE LISTENING=PARAPHRASING AND ACKNOWLEDGING
The ability to listen is an important therapeutic skill.
It improves inter-personal relationships by:
- reducing conflicts
- strengthening cooperation
- fostering understanding
- calming others (it is comforting to be understood)
Active listening is a structured way of listening and responding to others. It focuses attention on the speaker. It is important to observe the other person’s behavior and body language.
Having heard, the listener may then paraphrase the speakers words. It is important to note that the listener is not necessarily agreeing with the speaker simply stating what was said.
In emotionally charged communications, the listener may also need to listen for feelings.
The benefits of active listening include getting people to open up, avoiding misunderstandings, resolving conflict and building trust
Always, present the facts without making judgments or getting emotional, state expectations calmly and simply. If you are directing the patient to change a behavior, be specific and clear as to what you are requesting of them to end the situation. End with a question to gain agreement. Allowing the patient to be a part of the solution is always best, but the safety of the unit must be at the forefront of any discussion.
Staff Responsibility After the Event
Once a crisis situation is over it is important to assess the other patients. An aggressive incident can lead to problems with other clients such as:
Use the agency’s incident report and follow established protocols and procedures.
When writing the incident report:
- Be as specific as possible
- Do not use vague pronouns or emotional language
- Do use concrete language
- Write in simple, straightforward sentences
- Identify the perpetrator and victim/s
- Explain behavior clearly
- Identify any known precipitating events
Be sure to communicate with the next shift. Patients who were victims or witnessed the event may be upset or agitated. Aggression often leads to more aggression; therefore staff on subsequent shifts should be alert.
-Supervisors or managers should process the event
-Identification of precipitating events is important
-Root cause analysis may be done
-If possible, identify steps to take or changes to make to prevent a similar incident from happening again
Professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients in regard to personal safety and patient rights have changed the mental health and addiction fields.
Many facilities do not employ restraints. However, in an effort to inform we will briefly discuss these.
The term restraints include the use of seclusion, physical restraint, mechanical restraint and chemical restraint.
The only indications for the use of seclusion and restraint are to prevent dangerous behavior to self or others and to prevent disorganization or serious disruption of the treatment program. The use of restraints must be in accordance with the facilities policies and procedures.
Seclusion and restraint should not be used as punishment for patients, for the convenience of the program, where prohibited by state guidelines, to compensate for inadequate staffing patterns, or instituted by untrained staff. In facilities that employ these measures, for the safety and well being of the patients, the autonomy and dignity of the patient must be preserved as much as possible.
The decision on when to seclude or restrain a patient must be made by the professionally trained staff working with the patient at the time of the aggressive behavior in consultation with a physician. Seclusion, physical restraint, and chemical restraint should not be ordered on a prn (pro re nata = as the occasion may arise) basis. All patients in seclusion or restraint must be monitored continuously. There are strict requirements for the monitoring of pulse, blood pressure, range of motion, nutrition, hydration and comfort. With a release in place, the patient’s family should be informed of use of seclusion or restraint.
Physical and mechanical restraints that cause airway obstruction must not be employed, such as choke holds or covering the patient’s face with a towel, bag, etc. With supine (face up) restraints, a patient’s head must be able to rotate freely. With prone (face down) restraints, the patient’s airway must be unobstructed at all times (i.e. not buried), and the patient’s lungs must not be restricted by excessive pressure on the patient’s back.
Chemical restraint is the involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior. Chemical restraint is to be distinguished from the pharmacological management of a patient’s underlying illness.
The use of seclusion and or restraint should be followed by a debriefing discussion that allows the patient to process and understand what has happened. The staff should review with the patient the events that triggered the seclusion or restraint; discuss with the patient alternate strategies to avoid similar incidents and arrange whenever possible for the patient to make amends or do restitution to those who have been injured.
Every episode of seclusion and restraint must be documented in the patient’s medical record. The Joint Commission requires that patients be allowed written comment about the experience. Staff participating in a seclusion or restraint should review the episode in a separate debriefing session and document recommendations and findings for the facility’s committee that reviews seclusion and restraint reports.
Strong clinical leadership is essential in the management of aggressive behavior in order to minimize the need for seclusion and restraint. Facilities must have a committee that provides oversight of the practice of seclusion and restraint. This may include a review of restrictive interventions; restraint equipment; staff training; staff retention; and peer review of the application and use of seclusion, mechanical and chemical restraint, and restraint equipment. A patient and family ombudsman should also be available to review concerns about restrictive interventions if a facilities wishes to employ these methods.
Aggressive Behavior in Summary
Aggression is broadly defined. It can be physical, mental or verbal. Aggression and violence is frequently preventable by being watchful of warning signs and knowledge regarding individuals triggers for aggressive behavior.
Active listening and cognitive restructuring can be used to de-escalate an angry or potentially aggressive patient.
If an incident does occur, employ crisis intervention techniques, notify supervisors immediately and complete an incident report.
Repeated training in the management of aggressive behavior is necessary to develop the high degree of competence this work requires. Good training promotes the retention of qualified staff, safety of patients and staff and better treatment outcomes.
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