Today's POTD will be on de-escalating the agitated patient in the emergency department. We frequently encounter patients who are agitated for a variety of reasons, so let's talk about how we can provide the best possible outcomes for the staff and for the patient in these situations.
When approaching an agitated patient, approach with 4 main objectives:
1) Ensure safety of patient, staff, and others in the area
2) Help the patient manage their emotions and distress and maintain or regain control of their behavior
3) Avoid use of restraints if possible
4) Avoid coercive interventions that escalate agitation
Really, the biggest thing is maintaining patient and staff safety. Make a quick assessment as to whether this patient is mildly, moderately, or severely agitated.
If your patient is mildly or moderately agitated, verbal de-escalation should typically be your first go-to. Physical and chemical restraints have both been found to increase length of stay and are associated with higher likelihood of psychiatric admission, so if verbal de-escalation is a safe option in your patient encounter, it should be attempted first.
Guidelines for verbal de-escalation
Richmond et al. (2012) published ten domains for de-escalation that I find to be helpful. They are summarized in this table:
1: Respect personal space
Maintain at least 2 arms' length of distance between you and the patient. Also, make sure you know where the exits are, and make sure the patient is not positioned between you and the closest exit.
2: Do not be provocative
Pay attention to your body language. Be calm and avoid clenching your fists or concealing your hands.
3: Establish verbal contact
Have one main point of contact for the patient to avoid confusion and further agitation.
4: Be concise
Try to keep the information you're conveying simple, as agitated patients may not be able to process complex information quickly.
5: Identify wants and feelings
Use open-ended statements to understand what it is that the patient wishes to get out of the encounter.
6: Listen closely to what the patient is saying
Use active listening to understand what the patient is saying.
7: Agree or agree to disagree
Find something about the patient's position to agree with - even if you don't agree with their whole statement.
8: Lay down the law and set clear limits
The patient should know about acceptable and unacceptable behaviors, and boundaries should be clearly set.
9: Offer choices and optimism
The ability to choose can empower a patient.
10: Debrief the patient and staff
Have a discussion amongst the staff about what the plan is if the patient continues to be agitated or escalates their behavior. Also, discuss with the patient and family why certain measures were necessary.
If verbal de-escalation doesn't work or is not safe to attempt:
Physical or chemical restraints can be used. Physical restraints should never be used on their own without chemical sedation.
I won't go into all the nitty gritty about physical/chemical restraints in this POTD, but generally, if you're having to sedate the patient or physically restrain them, make sure the patient is somewhere visible to a staff member at all times and their ABCs are being monitored.
Finally, know your resources!
Luckily for us, we have an on-site ED psychiatry team, mental health workers, and security who are all trained in how to manage an agitated patient, so if you ever find yourself in a potentially unsafe situation, know your resources and don't go into it alone.
References:
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864
https://www.crisisprevention.com/blog/general/de-escalation-tips/
https://www.crisisprevention.com/en-GB/blog/general/cpi-top-10-de-escalation-tips/
https://litfl.com/de-escalation/
https://emergencymedicinecases.com/emergency-management-agitated-patient/
