Portal de Periódicos da CAPES

Special Report

2022; Lippincott Williams & Wilkins; Volume: 44; Issue: 8 Linguagem: Inglês

10.1097/01.eem.0000855776.83201.00

1552-3624

Gina Shaw,

Healthcare Decision-Making and Restraints

Figure: BETA Project, patient agitation, de-escalation, Parkland HospitalViolent assaults on emergency medicine residents at Parkland Hospital in Dallas were out of control: Some 28 percent of 50 residents had been physically attacked, according to the ED's internal survey. Eighteen months later, that number had dropped to under eight percent. The difference? Parkland added an order set for managing acutely agitated patients to the electronic medical record and an educational curriculum for clinicians based on Project BETA, the Best Practices in the Evaluation and Treatment of Agitation. (JACEP Open. 2020;1[5]:898; https://bityl.co/Ctxy.) “Part of the reason agitation is so difficult is because usually people who are agitated are not all that nice to deal with,” said Michael Wilson, MD, an author of the Project BETA recommendations and an associate professor of emergency medicine at the University of Arkansas for Medical Sciences who has a secondary appointment in the department of psychiatry. “They curse at us, they hit the staff, and emergency physicians obviously don't want that in their ED. Virtually every study I'm aware of on agitation management has as its outcome how quickly we can make people sedated, not even calm but sedated.” That led to a culture in the early 2000s of restraint and sedate that excluded other methods for calming patients. “When someone would come in and get a little disruptive, we'd run up with syringes of meds and sedate them heavily,” he said. Recognizing that this culture was not good for patients or providers—many of the injuries sustained by physicians and staff occur when patients are being restrained—led to the development of Project BETA in 2012. Project BETA, an interdisciplinary initiative led by the American Association for Emergency Psychiatry, brought together experts in psychiatry, emergency medicine, nursing, psychology, and social work. It articulated five overarching principles: Verbal de-escalation as a first-line treatment for agitation Pharmacotherapy that treats the most likely etiology of the agitation Appropriate psychiatric evaluation Appropriate treatment of associated medical conditions Minimizing physical restraint and seclusion Agitation should be treated as a symptom, not a diagnosis, Dr. Wilson said. “Just like we would never use the same antibiotics on every septic patient without trying to identify the source of infection, we should not treat agitation due to methamphetamine intoxication the same way we'd treat intoxication in someone who is schizophrenic and off their medication or someone who is hypoxic or hypoglycemic.” But that's exactly what the literature says about managing agitation, Dr. Wilson explained, and that's how it was often approached, using the term “undifferentiated agitation” as a diagnosis to give the medications they planned to give anyway. He said oral medication is appropriate for most patients but not all, especially if verbal de-escalation is used first. “A number of studies, not surprisingly, have shown that oral medications have fewer side effects than injected medications,” Dr. Wilson said. “While some people still believe that oral medications don't work as effectively, the fact is that while injected medications do have a faster time to peak plasma concentration, the clinical effect in the few studies that have examined this is absolutely equivalent.” A Success Story Parkland is one of the busiest EDs in the country, with more than 240,000 patients a year and eight emergency medicine attendings in the ED 24 hours a day. “I realized that people were just accepting violence in the ED as part of the job, and it didn't have to be,” said Lynn Roppolo, MD, one of the BETA authors, a professor of emergency medicine at UT Southwestern, and the former associate director of the emergency medicine residency program. “There is a lot of evidence that suggests we can risk-stratify patients based on their level of agitation and use the BETA recommendations to de-escalate them before restraint becomes necessary,” she said. “It's well established that most assaults in the ED happen when you are trying to restrain or sedate a patient.” De-escalation is the foundation of the BETA recommendations, and it involves a combination of verbal and nonverbal strategies aimed at calming patients and getting them to cooperate. “Patients who are able to make eye contact and engage in any form of conversation are more likely able to be de-escalated,” Dr. Roppolo and her colleagues wrote in the study. “De-escalation is a powerful tool to reduce a patient's agitation, build trust with caregivers, and mitigate violent acts, but requires an empathetic attitude, patience, and sincere interest in helping the agitated patient regardless of their history or clinical presentation,” they wrote. “It has really changed my practice. You need to partner with the patient, be kind to them, try to understand the clinical and environmental factors that may have led to their agitated state, and try to bring them down.” Dr. Roppolo said she has used de-escalation to avert violent assault and the need for restraint in several agitated patients. One patient in police custody kept getting up, his voice becoming louder, when an officer yelled at him to sit down. Dr. Roppolo learned after looking at the patient's medical record that he had a history of schizophrenia and was supposed to be on medication. She introduced herself to him by name, at a safe distance, and called him by his name and said calmly, “I'm trying to help you. I have some medication you're supposed to be on that I can give you right now. I can imagine you're hungry, so if you take this, I'll give you a sandwich and something to drink.” The patient was willing to take an olanzapine tablet and then ate a sandwich. And he didn't make a peep even though he was in the ED for hours. Another severely agitated patient came to the ED in handcuffs and was being held down by multiple officers. Everyone was asking her to order a syringe of lorazepam and haloperidol, she said. “But after being trained in BETA principles, I decided to try to de-escalate first. I kept saying to him calmly, ‘Mr. Smith, I am Dr. Roppolo. I'm here to help you, but you have to calm down.’ I said that over and over, again from a safe distance, and made eye contact with him,” she said. The patient began to respond to her, and Dr. Roppolo asked everyone except for one officer to leave the room. “He was trying to talk to me, but I realized he had a speech impediment,” she said. “I sat with him for five to 10 minutes, which is long in the ED, and I finally was able to understand that he was getting sexually assaulted at his group home and didn't want to go back there. “That's why he was fighting. I told him, ‘You are safe here. We are going to find you a new place. We won't hurt you in any way. We'll give you some food and a blanket, and we can take the handcuffs off if you stay in your bed.’ The officer stayed at his bedside. I called our social worker, and this guy was out of the ED with no forced medication or restraints, and went to a new group home.” Mastering Verbal Judo Strategies for verbal de-escalation dubbed “verbal judo” were the subject of a 2021 “Stimulus” podcast by Rob Orman, MD, when he talked with Joseph Pacheco, RN, the facility director and nurse operations manager with Guidewell Emergency Doctors in Clearwater, FL, and Dan McCollum, MD, an emergency physician at Augusta University in Georgia. Verbal judo was a term first coined in a book of the same name by former police officer George Thompson, who described it as staying calm in the midst of conflict, deflecting verbal abuse, and offering empathy in the face of antagonism. “I try to come in humble, at eye level, with a vibe of where they're at,” said Mr. Pacheco, whose colleagues call him the drunk whisperer. “I'm always at the door, palms out, showing them, ‘Hey, can I come in?’ I believe in coming in in a very kind, generous state. Most of the time this is people's worst day ever, so coming in in a very humble, kind approach helps. If they're angry, I bring the volume down to where they almost have to bring their volume down as well. Keeping eye contact is huge. A lot of people will feel completely uncomfortable and disarmed if you use direct eye contact. And the one thing you don't want to do is take your eye off the prize.” It's just being nice, said Dr. McCollum. “Acknowledging that no agitated patient chose this as plan A. It's about having empathy, preserving the relationship, and just checking in to make sure things are OK. And any sort of minor bribery,” he said. “We've had the conversation about the number of milligrams of lorazepam equivalent to a turkey sandwich, knowing when you can bend while still keeping things safe. As the patient gets more agitated, be more clear that if [the patient continues] that behavior, things will get worse. How is it that we can work together to avoid that situation because neither of us want that?” When agitation increases to the point that medication might be needed, Dr. McCollum has a tactic for suggesting oral medications to patients, saying, “You seem a bit anxious. Would you like something to help calm you down?” Many patients are looking for medication because they recognize that they are agitated and upset, he said. “It's hard to predict when things will escalate and you need to be ready for things to escalate, but I rarely have to restrain when we use those techniques,” Dr. McCollum said. “It really is amazing how, as long as you have that empathy, it becomes more of a mirror. I can see myself in you, as opposed to this antagonistic wrestling match.” Dr. Orman, an emergency physician who now works as a physician career coach, outlined on that podcast what he called the Universal Upset Patient Protocol, which involves listening, not interrupting, and seeing it from the patient's perspective. Also ask what you can do to help, and offer a plan for what you would like to do next. Present an alternate plan rather than rejecting their plan outright if what they suggested was unreasonable, he said. “Sometimes through this, you're even getting something you missed earlier that could have led to a catastrophic outcome in the end,” Dr. Orman said. The BETA recommendations do acknowledge that physical restraint can sometimes be necessary. “Patients who require physical restraint should receive calming medications to reduce the psychological and physical trauma as well as the medical complications associated with being restrained. At least five individuals are needed to restrain patients: one on each extremity and one at the head of the bed,” said Dr. Roppolo. “Precautions should be taken to prevent harm to the patient such as not covering their mouth or compromising the patient's ability to breathe. The nurse should administer the calming medications via intramuscular injection only if it's safe to do so, which is when the patient is appropriately restrained and cannot injure the nurse while medications are being administered. Agitated patients need to be closely watched at all times for safety, including cardiac monitors, pulse oximetry, and capnometry, if the patients are sedated.” Building on BETA Now that 10 years have passed since the BETA recommendations were released, Dr. Wilson and his colleagues said it might be time for an update. Ambrose Wong, MD, a physician-scientist in Yale's department of emergency medicine, said incorporating consideration of structural and racial bias into BETA would be helpful, as would applying it in the real-world environment of the ED. “One thing we are working on now is creating a decision support system, where BETA is embedded within the health record and workflow, so that applying it becomes streamlined,” he said. Data from the health record might be useful for triaging patients who are at the highest risk for agitation so resources can be deployed effectively, Dr. Wong said. “If a person is flagged to be more likely to become agitated, there may be deliberate interventions we can use upfront, such as making sure the person isn't slotted in the hallway, getting them something to eat, and ensuring they have gotten any daily medication they are supposed to take, to pre-emptively avoid an episode of agitation,” said Dr. Wong, who has published extensively on managing agitated patients and using restraints in the ED. More tailored training and education in de-escalation focused on the ED are also needed. “While our ED staff do get training and then refresher courses from a commercial crisis prevention vendor, with a focus on de-escalation and recognizing safety issues, the staff sometimes tell me that the training is not specifically applicable to the ED,” he said. “There are over 20 different commercial crisis programs that hospitals can purchase, but nothing that is standardized for the unpredictable environment of the ED.” Dr. Wong has also been investigating using patient advocates to help with de-escalation. “These people know what it's like and can advocate for the patient, help them express frustrations, and translate between the clinician and patient. I could see this working in the ED, with a trained patient advocate who could respond as part of the agitation team, noticing things the clinician might not pick up. We are now putting together a grant proposal to explore this approach,” he said. Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work athttp://www.writergina.com/Home.html. Follow her on Twitter@writergina.