New Guidelines Shake Up Treatment of Agitation

Agitated individuals-defined as displaying “excessive verbal and/or motor behavior”-can be loud, disruptive, hostile, sarcastic, threatening, hyperactive, and even combative. Agitation is a common occurrence in emergency settings, estimated to occur nearly 2 million times per year in the United States alone. A patient acting in an agitated way is traditionally dealt with sternly, with large, strong staff members and security personnel who typically “take down” the patient physically, and then forcefully restrain him or her to a bed using thick leather shackles. Next, clothing is lowered and as many as 3 painful sedative medications are injected into the bare hip.

This rather harsh sounding process, also known as “restrain and sedate,” has been a standard of practice for many years. The approach has staunch advocates, who insist that it is the best means of maintaining safety for the staff and others in the area. But this stance can fail to recognize that at the center of this raucous activity is a human being- one who is commonly very scared, vulnerable, and fragile - and that the acts of forcible restraint and involuntary medication can often cause more harm than good. Further, quite often, takedowns, restraints, and injections can be easily avoided, in a way that is safer and faster -while improving both short- and long-term outcomes.

More humane, patient-centered interventions for agitation are endorsed as part of new, comprehensive best practices guidelines, published this month with open access in a 6-article special section of the Western Journal of Emergency Medicine.¹ Called Project BETA-an acronym for Best practices in Evaluation and Treatment of Agitation-the articles are the summation of 16 months of work and over 30 physicians and mental health professionals collaborating under the auspices of the American Association for Emergency Psychiatry (AAEP).

Past guidelines for agitation have primarily focused on medication strategies. Yet Project BETA differs in recognizing that not only can agitation result from myriad origins, but its treatment is multifaceted, with pharmacology only playing one part. Thus the guidelines address the entire agitation clinical spectrum, including triage, diagnosis, and interpersonal calming skills, as well as medicine choices.

The articles are designed to be interconnected and part of a complete therapeutic approach, with the soothing techniques collectively known as “de-escalation,” an important component to all aspects of agitation treatment. Some who question this philosophy may argue their busy emergency department does not permit time enough to attempt to engage with the patient -but they might be surprised to find these methods can often be much faster than “ restrain and sedate.”

BETA Chair Garland H. Holloman, Jr, MD, PhD, of the University of Mississippi Medical Center in Jackson, Mississippi, writes, “Verbal de-escalation can typically be quite effective in a relatively brief period, while placing a patient in restraints can require significant staff involvement-from the time needed to ‘‘take down’’ and restrain the patient to the obligation for one-to-one observation .”²

It is perhaps not often recognized that agitated patients can be very paranoid, delusional, and frightened by their symptoms and surroundings. Their agitation is thus more of a “fight or flight” response than actual belligerence. Agitated patients commonly want help and respond positively to collaborative, empathetic clinicians. The articles thus encourage a therapeutic alliance between staff and patients, and provide helpful step-by-step principles and algorithms to guide professionals in calming individuals without resorting to force.

The articles also report that safety is typically improved by such non coercive approaches, noting that as many as two-thirds of staff injuries involving assaultive patients occur during the avoidable physical “ takedown” process. Studies are cited showing facilities with reductions in restraint use decreasing in staff assaults and injuries as well.

Patient-staff collaboration extends to the pharmacology article also, with calls for involving patients in medication decisions, using orals over parenterals when possible, and choosing agents with more benign side-effect profiles. Treatment recommendations are delineated by etiology of the agitation, with several alternatives for each category.

The authors do note that in the present day, total elimination of the use of restraints and coercive treatments may not be possible but that attempts to decrease such interventions are worthy. Quoting the introduction, “It is hoped that these guidelines will assist clinicians in recognizing that agitated individuals need not necessarily go straight into restraints, but instead can be treated in a more benign, collaborative fashion, which will lead to less injuries, better therapeutic alliance, improved throughput and superior long term outcomes.”²

Table. Highlights of Project BETA’s new guidelines for agitation
-De-escalation can work far more often than many clinicians might be aware; it is nearly always worth attempting verbal calming as part of agitation treatment approaches
-De-escalation to the point of patient cooperation can be faster and safer than takedowns, restraints and injections
-Voluntarily taken oral medications are preferable to forcible involuntary injections and enhance therapeutic alliance
-Second-generation antipsychotics are as efficacious as first-generation antipsychotics in agitation, and preferable because of side effect profiles
-Stimulant intoxication agitation should be treated with benzodiazepines alone
-Emergency programs that have reduced use of restraints do not show increased staff assaults, and frequently have fewer staff assaults and injuries

References1. Behavioral Emergencies: Best Practices in Evaluation and Treatment of Agitation. See: West J Emerg Med. 2012(13):1. http://escholarship.org/uc/uciem_westjem?volume=13;issue=1. Accessed March 27, 2012.
2. Holloman GH, Zeller SL. Overview of Project BETA: Best practices in Evaluation and Treatment of Agitation. West J Emerg Med. 2012;13:1-2. http://escholarship.org/uc/item/4kz5387b [pdf]. Accessed March 27, 2012.