dean marks - western health

Physiology of Response

Calm in the Face of a Storm

27/09/2016 Prepared by: D Marks – Security Services Mgr – Western Health 1

27/09/2016 2Prepared by: D Marks – Security Services Mgr – Western Health

Act

STANDARD PROCESS

WHAT IS HAPPENING NOW?

CODE PURPLE

CODE YELLOW

CODE ORANGE

CODE BLUE

CODE GREY

CODE BLACK

CODE BROWN

• Facility Focused• Annual Training• Some F2F Training• Online Training

• Clinically Focused• Clinically Led• Clinically Concluded• Face to Face• Ongoing Continual Training

CODE RED


• Clinically Led• Aggression Focused• Security Concluded


In 2014, the Victorian Department of Health delivered a document to industry, ‘Standardsfor Code Grey Responses’.

This document defined separated Code Black and Code Grey.

• Clinical aggression: Aggression arising from the health condition and which occurs between a health professional and a patient (or visitor).

• Code Black: A hospital-wide internal security response to actual or potential aggressioninvolving a weapon or a serious threat to personal safety (ASA 4083).

• Code Grey: A hospital-wide coordinated clinical and security response to actual or potential aggression or violence (unarmed threat). Code Grey activates an internal alert or emergency response.

The principle theme is AGGRESSION



Objective

To employ the most effective, humane interventions in occupationally aggressive and violent situations

to ensure the least possible physiological and psychological impact to both our staff and patients


• Aggressive

A domineering, forceful or assaultiveverbal or physical action toward anotherperson as an expression of anger,hostility or rage.

• Resistive

In contrast, to resist is "to take a stand;to exert force in opposition; to exertoneself so as to counteract or defeat."This resistance can be in the form ofdefiance as well as physical resistance

The point is that the intentions that underlie resistiveness differ from those that underlieaggressiveness.

In brief, the intention of aggression is offensive, whereas that of resistance is defensive.

Clearly, intervention should take into account whether the behaviours displayed aremotivated by the intent to cause harm, or by the intent to avoid being harmed, howeverrealistic or unrealistic the actual potential for harm may be.

A vast majority of the situations we deal with on a daily basis are in fact resistive behaviours.

Understand & Assess before Acting

RESISTANCE CONTROL PARADIGM

Psychological

ResistanceNon Verbal cues in attitude, appearance, demeanor or

Posture That indicate an unwillingness to cooperate

Verbal

Resistance

Verbal responses indicating unwillingness

to work with you and/or comply

Passive

Resistance

Physical Actions that demonstrate resistance

but do not prevent attempts to control

Defensive

Resistance

Physical Actions which attempt

to prevent control but not harm

Active

AggressionPhysical Actions

of assault

Aggravated

Active Aggression


CLINICAL

PainFatigueDrugsAlcoholMental DisorientationHead InjuryInfectionMetabolic Instability

NON-CLINICAL

LanguageEthnic OriginReligionBelief SystemCulturePast ExperienceFearAnxiousnessThreatenedFrustrationPowerlessnessCopingGrief


Clinician

Security

Volunteers

Engagement

Verbal De-escalation

Diversion

PRN Meds

Mechanical Restraint

Family

Patient Mgt Plan

Chemical Restraint

Clinical Options Model


Security

Physical Restraint

Verbal De-escalation

Mechanical Restraint

Security Options Model


Phases in the Restraint Process

• Phase 1 - Onset

• Phase 2 – Intervention

• Phase 3 - Initiation

• Phase 4 - Struggle

• Phase 5 - Transition

• Phase 6 - Release / Retention

Phase 1 - Onset

• No matter WHAT kind of emergency condition causes the patients PHASE 1 - Onset, the patient isbeing cued to act out in an unusually aggressive or violent, emotionally and physically exertivemanner. The patient may be unable to consciously control their behaviour, and entirely unable tovolitionally respond to verbal counsel or de-escalation techniques.

• The moment it starts, the emotional and physically exertive behaviour begins to physically exhaustALL of the muscles in their body.

• Unless you have triggered the event or are in direct close proximity when the event initiates, anyinjury is unlikely to be sustained, however, the patient may self harm.

Phase 2 - Intervention• The initial stage of intervention should always commence with “Tactical Verbal De-escalation”

designed to solicit a non-physical compliant response from the patient.

• Any introduction of a new level of force should be led by seeking verbal compliance. Should theperson be performing violent or aggressive exertional activity, no matter who the responders are,no matter what initial setting or circumstances are involved, the patient is involuntarilycompelled to RESIST any attempts to stop them.

• The Intervention Phase seeks verbal compliance. As long as “safe separation” is maintained whichfacilitates a “reactionary gap”, injury is rarely sustained.

• The majority of situations may be resolved at this stage by utilising appropriate approach designedto recognise and diffuse resistive behaviours.


“Safe Separation” and the “Reactionary Gap”

• What we are looking at are Proxemics. Themanagement of personal space and thetime required to respond to an act ofaggression.

• As shown, the “intimate zone” isapproximately 18 inches in front of us withthe “personal zone” being about 3 feet. Atour sides, both the personal and intimatezones are approximately 18 inches,however, the personal zone to the rear isapproximately 5 feet. We are generallymuch more comfortable with anotherperson standing or sitting beside us withoutfeeling uncomfortable than directly in frontor behind.

• Personal space varies with each and everyperson based on differences in culture,environment, personal habits, gender andage.

• When we discuss “Reactionary Gap” , this isthe time you have between identifying anattack and reacting to it. As a general rule,if you are within 4 feet of the person andthey decide to attack you, there is very littleyou can do about it. Their “action” time willusually beat our “reaction” time.


Phase 3 - Initiation• The moment Responders begin to employ "normally-effective," minimally-restrictive, techniques of

hands-on restraint, they immediately discover that the patient is INCREDIBLY STRONG! In fact,Responders almost immediately realize that minimal to moderate amounts of force, minimal tomoderate amounts of restraint, are entirely unable to safely or effectively "contain" the individual'smovements.

• The physical exhaustion experienced by the patient during PHASE 1 and 2 is increased (worsened) bythe physical exhaustion suffered during the initial struggle with Responders.

• Initiation involves closing the “Reactionary Gap” and making direct contact. Without a clearlydefined approach strategy and consistently trained physical intervention skills, both the patient andresponders are at high potential for injury at this point.

• On touch, the person being restrained will resist.

Phase 4 - Struggle• PHASE 4 An increasing number of Responders begin applying an increasing amount of restraint

(and restraint force) rapidly progressing to a maximum, "full-body," form of restraint.

• The physical exhaustion continues to increase. Muscular activity causes excessive "lactic acid"production. The longer the over exertive muscular activity continues, the more lactic acid isreleased into the patients system, and overdose can occur – "profound metabolic acidosis." Thebody's natural (involuntary) response is to "correct" it by hyperventilating.

• States of extreme emotional and physical exertion also generate excessive production of severalother naturally-produced body chemicals; especially the chemicals released by the "Fight/Flight"nervous system, such as adrenalin and noradrenalin.

• Once the Struggle Phase commences, the propensity for significant injury increases exponentially.Factors with respect to the responders such as; number of persons involved, environment,emotional control, fitness, age, prior experience and knowledge, skill ability and consistency oftraining, become completely relevant with respect to a successful, injury free outcome. Thesefactors are also directly relevant with respect to the patient, in addition to factors such as mentaland cognitive state, drugs, alcohol etc.


Phase 5 - Transition• PHASE 5 begins when the Responders attempt to move or transition the patient from the "full-

body," form of restraint to a subsequent location.

• Prior to transition, the Responders must ensure the patient has calmed and is compliant to ensurethe safety of all persons during the move.

• Uneducated restrainers misinterpret any continued struggling and muscular activity as an indicationthat the individual is "still breathing" and/or still "fighting" with them. Consequently, restraint iscontinued until compliance is gained as the responders believe it is still unsafe to commence thetransition Phase.

• The transition from full body prone restraint to restrained standing and then walking is fraught withdanger for all concerned and the vast majority of injuries occur at this point. Should the patientviolently struggle or strike out, they will be taken back into prone restraint and the subsequentphysiological effects on the patient will be compounded to their detriment.

Phase 6 – Release / Retention

• On completion of transition of the patient to a safe environment, the patient will be released fromphysical restraint or placed into mechanical restraints.

• The decision to release or place into mechanical restraints must be clinically made.

• This decision MUST take into account the safety of the patient, hospital staff, other patients andvisitors.

• When a patient is released from physical restraint, Responders must ensure they are in a safeposition to do so as the patient may strike out on feeling the restraint release.

• When a patient is advised they will be placed in mechanical restraints, the Responders may befaced with an immediate return to Phase 3 and 4 and are faced with a patient who once again isover exerting and displaying “super strength” in order to break free.

• Should restraint be dictated, forceful supine full body restraint is required. Within a room orcubicle, space is limited and the ability to maintain a full restraint can be limited.



Self Control Cycle

SC = I/E

I/E + P = E/I

E/I + T = I/E

I/E = SC

Self Control is directly proportional to the typeand consistency of training undertaken specificto the situation being faced.

Whenever a problem is introduced into thecycle, unless constant training and andenvironmental inoculation are undertaken, theresponders emotions will have a direct effect onthe outcome.

As can be seen in the previous slides, at each ofthe 6 individual phases of restraint, new,specific problems are introduced. Theassociated “response risk” must be multipliedby the number of individual responders presentas each emotional state will contribute to thefinal result.

SC = Self Control

I = Intellect

E = Emotions

P = Problem

T = Training Regime


What are the Problems

We may do the same job, however, we are not the same people.

Different backgrounds, experiences, ages, builds, sizes, genders, fitness levels,attitudes and beliefs.

SO WHY DOES THIS MATTER?


What are the Problems• Survival Stress • Endurance Limitations

It can be best defined as;

• the stress that occurs on a person when they are “startled” by an imminent threat of serious personal injury,

• The stress that occurs when a persons time to respond to a threat is minimal,

• The stress that occurs when a person is responsible for protecting themselves in a potentially life threatening situation,

• The stress that occurs when a person does not have confidence in their skill level to control the threat.

Commonly known as “fight or flight”

The body relies primarily on 3 energy systems;

• ATP/PC (adenosine triphosphate /phosphocreatine)

High energy, high strength at 100%.System burns out after 10-15 seconds.

• Lactic Acid:Provides about 45 seconds of intermediatestrength and endurance. Maximum outputwill reduce to 55% (of max output) at 30sec and then drop to 35% (of max output)at 60 sec.

• Aerobic:Around 90 sec into a confrontation, theAerobic System becomes the final anddominant fuel system. The system iseconomical and can burn for long periodsdepending on the personscardio/respiratory conditioning. However,the persons maximum output will bereduced to approximately 31%.


Why are these Problems

Because, when there is a requirement for one or more persons to take forceful physical control of anther person, the physiological and psychological attributes as described will be different for every individual person involved.

Add to the equation a highly psychomotor agitated patient with what appears to the responders as “Super Human Strength”

As the responders start to struggle with energy levels diminishing, they will become emotionally heightened and fear injury should the restrained patient break free.

At this stage, responders will escalate their level of force to control the patient. This escalation may result in a substantial injury to the patient that could have been avoided.

Not only is there an increased risk of injury to the patient, there is also significant risk of a serious injury being sustained by responding staff during the Intervention and Struggle Phases, and in particular the Transition Phase.

In short, any physical engagement needs to controlled within the first 10-15 seconds or the risk of injury to all persons significantly increases.

Getting Real About Response


OUTCOME R TRAINING + CONTENT x FREQUENCY

Importance Difficulty Training Frequency

1Not Important. Would not affect the outcome at all

1 Very Low level of difficulty 0 Not Performed

2Low. May have a slight impact on the outcome.

2 Low level of difficulty 1 Annually (1-2 times a year)

3Moderate. Would have some impact on the success of the outcome.

3Moderate level of difficulty

2Quarterly (3-4 times a year)

4

High. Successful outcome would be difficult to achieve if not performed properly.

4 High level of difficulty 3Monthly (1-3 times a month)

5Very High. Outcome would not be successful if done improperly

5 Very High level of difficulty 4 Weekly (1-5 times a week)

5Daily (1 or more times a day)



OUTCOME R TRAINING + CONTENT x FREQUENCY

COURSE VERBAL SKILLS PHYSICAL SKILLS

MAPA a a

MOAB a a

MOAT a a

MOCA a a

VJ a

PART a a

CMI a a

HETI a

FREQUENCY R IMPORTANCE

Neural Basis of Response Programs

The speed at which a new program is learned will be affected by variables such as the complexity of the skill,Presentation and the applicability of the skill for the dynamic applications.

Neural programs are strengthened the more the program is repeated due to myelination. As the myelination Increases, so do the fluidity and speed of the techniques.



CONDITION / STIMULUS RESPONSE TRAINING

Although repeating the process is important, it is critical to ensure the response is taught in recognition to a stimulus or threat.

It is not just teaching the physical skill, it is ‘hard wiring’ the response instead of ‘soft wiring’ the response into behaviour.

HOW ?

We use Static, Fluid and Dynamic Practice Methods.

We then reinforce through through regular, short, in-service simulations and mental (desktop) exercises. By doing this we move away from process ‘static risk assessment’ and learn to apply fluid ‘dynamic risk assessment’ principles that permit us to move through a response and constantly gauge effectiveness of chosen pathways and change as required to achieve more effective outcomes.


Analyze: What has happened? Identify the foreseeable risks.Constantly review ongoing situation.

Evaluate: What policies & procedures are in place to address and assist with this situation.

Identify: Controls and resources available to assist you indealing with and managing the situation. Evaluate limitations.

Organize: Organize and plan your response strategy and Resources. Understand outcomes & resource limitations.

Utilize: Execute and utilize your plan and response strategy



REFERENCES:

Better Responses, Safer Hospitals – Standards for Code Grey Responses: www2.health.vic.gov.au

Physical Intervention – Reducing Risk: http://www.nhsbsa.nhs.uk/i/SecurityManagement/FINAL_11102010_PI_Skils_for_Security.pdf

The Impact of the Sympathetic Nervous System on Use of Force Investigations: Bruce Siddle (Research Review)

Restraint Asphyxia – Silent Killer – The Pathophysiology of Restraint Related Positional Asphyxia: Charly D Miller

Management of Aggressive Behaviour: Roland Ouellette:

Decision making: A psychological analysis of conflict, choice, and commitment: Janis, Irving L.; Mann, Leon

Sharpening the Warriors Edge: Bruce K Siddle

A literature review and policy analysis on the practice of restrictive interventions in Victoria; Vic Gov, Department of Human Service

Aggression, Seclusion & Restraint in Mental Health Facilities in NSW; NSW Ministry of Health

The safety of nurses during the restraining of aggressive patients in an acute psychiatric unit; AUSTRALIAN JOURNAL OF ADVANCED NURSING Volume 29 Number 3

Ombudsman investigation into the Department for Correctional Services in relation to the restraining and shackling of prisoners in hospitals; South Australian Ombudsman

Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments; NSW Ministry of Health

Principles for Safe Management of Disturbed and /or Aggressive Behaviour and the Use of Restraint; NSW Ministry of Health

Blindsided, A Managers Guide to Catastrophic Incidents in the Workplace; Bruce T Blythe

Instructor Development and Training, A Guide for Security and Law Enforcement; Larry Gene Nicholson

http://www.nhsbsa.nhs.uk/i/SecurityManagement/FINAL_11102010_PI_Skils_for_Security.pdf

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