Outpatient Specialty Care and Primary Care Clinical Pathway
for Management of Behavioral Escalations

Person with Risk for Escalated Behaviors

Behavior Risk Assessment

Identify Behavior
Decide whether behaviors represent low, medium or high risk.
Change in body language, argumentative or defensive, verbal or physical escalation.
Verbal request to leave, movement towards exit, physical attempt to leave.
Actively Suicidal/Self Harm Behavior
Expressed thought to harm self/others, present injurious behaviors or plan, intent during appointment.
Threat to Harm Others
Expressed thought to harm others, present plan or intent during appointment.
  • Immediate Safety Actions
    • R.A.C.E. Response
    • Ensure safe room/location
    • Remove weaponized items
    • Staff access to door
    • Reduce visit time, as possible
  • Risk Based Response
    • Risks and protective factors may impact the response level and resources needed for support
    • In the boxes below, strategies and resources occur in order of suggested priority
  • Behavior Specific Response
    • Aggression
      • Remove other patients, visitors and unnecessary staff from space
    • Elopement
      • Monitor building doors
    • Actively Suicidal/Self Harm Behavior
      • Monitor safety
      • Re-evaluate the EOC for hazards and risks for items that could be weaponized
      • Referral to ED or Crisis Center, or dispositions in coordination with authorities (adults)
    • Threat to Harm
Successful De-escalation
Proceed with visit
Monitor Behavior


  • Team safe alert activated
  • Consider Duty to Warn
  • Consider consults to Child Life, HMHK, Social Work, or Psychology for future appointments
  • If patient escalation, team lead or physician should consider follow-up call to patient/ caregiver in 1-3 days.
  • KAPS Report
Recognizing a Behavioral Health Crisis
Stages of Crisis: The CPI Crisis Development Model
Crisis Development Behavior Levels Staff Attitudes/Approaches
1. Anxiety: A change in typical behavior 1. Supportive: An empathic nonjudgmental approach
2. Defensive: Protecting oneself from a real or perceived challenge 2. Directive: Providing clear directions or instructions
3. Risk Behavior: Behavior that presents an imminent or immediate risk to self or others 3. Safety Interventions: Non-restrictive and restrictive strategies to maximize safety and minimize risk
4. Tension Reduction: Decrease in physical and emotional energy 4. Therapeutic Rapport: Re-establish the relationship
Posted: August 2022
Authors: C. Wolfarth, MA; B. Loftus, RN; L. Blaskey, PhD; A. Tappon, CCLS; J. Ginsberg, DNP; D. Stephenson, MD; W. Wallace, DO; K. Dang, MD; A. Riisen, PsyD; N. Baird, MS; B. McGovern, LSW; J. Keller, DNP