Behavioral Escalations — Risks and Protective Factors for Consideration — Clinical Pathway: Outpatient Specialty Care and Primary Care

Behavioral Escalations Clinical Pathway — Outpatient Specialty Care and Primary Care

Risks and Protective Factors for Consideration

Presenting behaviors combined with vulnerabilities and factors may increase or decrease perceived risk, response level and resources needed for support.

Risk Factors
Represent aspects of the escalated person’s clinical presentation, history, environment, family and social context, and demographics that precede behavior and may increase risk for behavioral escalation and harm.
Protective Factors
Represent aspects of the escalated person’s clinical presentation, history, environment, family and social context, and demographics that may decrease the risk of behavior escalation. Protective factors can also help with advanced planning in situations (e.g., medical procedures) anticipated to lead to possible behavior escalation, as these protective factors can be used to formulate an approach to supporting the individual. Individuals with more protective factors may represent a lower risk for escalation in the care environment than a person who does not have as many protective factors, and information about protective factors should be integrated in conceptualization of overall risk.
  • Patients and families who follow the guidance below are at reduced risk compared with patients and families who are not able to demonstrate these factors.
    1. Maintain safety in their current environment
    2. Engage in using coping strategies
    3. Willing and able to follow recommendations
    4. Apply the steps of a safety plan in a crisis situation

Vulnerabilities and Factors for Consideration

Physical
  • Size and physical ability of the escalated person
  • Size/capability of support person (if present)
  • Presence of residential facility staff or guards
  • Forensic Patients Procedure
  • Number of people present for visit
  • Age of the person
Social/Emotional
  • Procedure/reason for visit
  • Past experience with medical care
  • Limited coping abilities
  • BH diagnosis
  • Developmental disorder or difference
  • Parent/child relationship
  • Language/cultural difference
  • Cognitive/developmental ability of the escalated person (patient and/or caregiver)
  • Substance use at time of visit
  • Stressors
    • Medical
    • Social/emotional
    • Recent life event
  • Trauma History Job Aid
  • Communication barriers
    • Limited language
    • Non-verbal
    • No expressive language
Environmental
  • Support available
    • Interpreter
    • Social Work
    • Security
  • Items on person and or present in the space that could be weaponized
  • Office layout
    • Isolated exam rooms
    • Size of room
  • Location of escalation
    • Waiting area
    • By the doorway
    • Long hallways
  • Noise
  • Staff availability
    • Early morning
    • After hours
  • Items in room
    • Phone
    • Equipment in the rooms
    • Access to supplies
    • Locks on cabinets
    • Sharps containers
    • Cords
Target of Escalated Behavior
  • Review chart and Past Behavior Safety Alert to determine pattern of behavior in presenting environment
    • Ask parent if child has targets of behavior at start of visit
    • Ask parent if child had any previous patterns of behaviors prior to visit
  • Determine focus behaviors are directed toward (self, parent, staff)
  • Determine best use of interventions based on target of escalated behavior
  • If behavior targets identified, add/edit to Past Behavior Safety Alert (also can create a nursing note and route to provider to consider adding diagnosis code to problem list)