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Special Report: Project BETA Stresses Verbal De-escalation for Agitated ED Patients

Scheck, Anne

doi: 10.1097/01.EEM.0000394575.73247.2a
Special Report
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When an agitated woman's nonstop screaming in the emergency department prompted a desperate call for a sedative, Scott Zeller, MD, who typically considers an injection a last resort, stepped in with a simple inquiry: “Would medicine help you?” he asked the ranting woman.

She ceased her top-of-the-lungs tirade long enough to tell him yes. He then administered the medication — orally. “I had someone [in on this case] telling me there was no way she would take it that way. Well, she did,” he said. The woman calmed down, and was hospitalized without further incident or need for physical restraint.

Another case of acute agitation. Dr. Zeller encounters them relatively routinely. “The numbers just keep going up,” he said, alluding to the increasing volume of agitated patients. (Primary Psychiatry 2010;17[6]:41.)

Such cases have compelled Dr. Zeller, who has been practicing emergency psychiatry for more than two decades, to try to find ways to show, cajole, or convince other emergency departments that one of the most successful approaches for agitation is delivered in words, not vials. Partnering with a patient, even a shrieking one, is entirely possible through certain techniques, including those that foster therapeutic alliance, he said.

Now, along with some like-minded colleagues, he has a tool for doing just that: Project BETA. The acronym stands for “Best Practices in Evaluation and Treatment of Agitation,” and it is a new, unprecedented guideline from the American Association for Emergency Psychiatry (AAEP).

Agitated patients are the classic GOMER of yesteryear, with “Get-out-of-my-ER” behaviors that can include incessant shouting, stomping feet, and pounding fists.

An important aspect to consider when seeing patients like this, however, is that these are people who are uncomfortable because “something is wrong,” said Leslie Zun, MD, a professor and the chair of emergency medicine at Chicago Medical School and the chair of emergency medicine at Mount Sinai Hospital. It is the expression of overwhelming discomfort that surfaces as agitation, he stressed.

The BETA project, which represents an AAEP-wide effort to collate relevant, peer-reviewed data and includes several working groups on different aspects of managing agitation, is a much-needed development, said Dr. Zun, who is on the AAEP board. BETA findings form a consensus statement that defines with much more precision “what is the best way to treat these patients, specifically agitation,” he pointed out. Agitation scales, which appear often in the psychiatric literature, appear to be seriously underused, for example. They should be utilized more frequently, with the same reliance as pain scales, and treatment needs to be based on the level of agitation, Dr. Zun said.

Dr. Zeller, the president of the AAEP and the chief of psychiatric emergency services at Alameda County (CA) Medical Center, said BETA will be pretty straightforward to use: step-by-step guidelines for clinicians and nurses with a flow chart and easy-to-follow recommendations. But will the document be equally easy to implement in EDs?

Not if recent history is any indication. Guideline use is notoriously inconsistent, even when it is mandated. In addition, resistance to change, like the ones proffered by BETA, is well-documented in emergency medicine (Ann Emerg Med 2008;51[1]:70.) And, as a result of some highly publicized incidents involving weapon-wielding patients or their family members, there is open fear among some health care providers that the very people who are seeking care can spiral out of control, erupting in violence. (JAMA 2010;304[22]:2530.) It is pretty well established that emergency physicians work with a “bias toward action,” which is an effective way to manage many patients, but one that can lead to “an indiscriminate approach” that results in less-than-optimal care. (Safe and Effective Medicine Use in the ED. Bethesda, MD: American Society of Health-System Pharmacists; 2009).

But the BETA guidelines have the potential to provide a huge advantage for EDs, according to Drs. Zeller and Zun. This is an approach that avoids restraints, encourages oral medication use over intravenous or intramuscular injections, and may enable health care providers to get at the root of the reason for the ED visit, rather than the patient “being knocked out, going to sleep for hours and hours, and waking up with the same [underlying] problem” that landed him there in the first place, Dr. Zeller said.

And it arrives at a time when economic turmoil is imperiling jobs, and, in turn, health insurance. In this downturn, four times as many unemployed people as working Americans — 13 percent of those jobless — have thought of harming themselves. And almost half report difficulty in obtaining health care, according to a 2009 national survey conducted in part for the National Alliance on Mental Illness. (Depression: Gaps & Guideposts; http://bit.ly/NAMIsurvey.)

Is that what accounts for some of the increase in ED use by those in acute agitation? “It wouldn't surprise me,” said Kevin Leicht, PhD, a professor and the chair of sociology at the University of Iowa in Iowa City. Paid work provides structure, prevents or mitigates financial strain, is often commensurate with insurance and gives a sense of identity that is essential for the well-being of many people, said Dr. Leicht. Moreover, the numbers of inpatient psychiatric beds have been diminishing, with some states, including Iowa, showing critical shortages. (Violence in the Emergency Department. New York: Springer Publishing Co.; 2009.)

Dr. Zeller relies on verbal de-escalation and therapeutic alliance, with great success, he stressed, by positioning himself as caring and helpful, using relaxed body language and calm, non-judgmental words.

“I have had people tell me ‘This won't work,’” he said. “I am saying it not only works, but it can work very quickly. This isn't 30 minutes of tell-me-about your childhood. It is standing there with a knee bent, hands at your sides, asking something like ‘How can I help?’”

Numerous studies have found that the link between using a new method and eschewing it comes down to personal experience. If it works, preference for it can be immediate. As has been noted in a consensus conference on knowledge translation by the Society for Academic Emergency Medicine, “the individual practitioner is a linchpin in the process of translating new knowledge into practice, particularly in the emergency department, where physician autonomy is high, resources are limited, and decision-making situations are complex.” (Acad Emerg Med 2007;14[11]:984.)

In the ED, agitation is usually due to a psychiatric cause associated with one of three main etiologies: intoxication, most commonly due to stimulants, bipolar disorder, or schizophrenia. The cause frequently is comorbid, making a diagnosis far more complicated: A bipolar patient off medication who becomes manic may take methamphetamine, for example, to heighten the exhilaration. The skill set needed for these patients is pretty straightforward, Dr. Zeller said.

He has a list of pharmacologic agents he depends on, but verbal de-escalation — speaking in short sentences in a low monotone that diminishes the level of arousal — means they are much more likely to be taken orally when possible. And if intramuscular delivery is needed, a willing recipient makes a better patient generally. After all, agitation is not the same as aggression, though there is overlap in some cases. In general, agitation is behavior that, while potentially destructive, is not directed at another person.

When asked why he seemed so averse to injections, which presumably quickly interrupt the agitated episode, Dr. Zeller noted that this can be unproductive on two counts. First, it can disrupt any hope of a therapeutic alliance, and may mean that the patient will be uncooperative despite the sedation, interfering with the ability to obtain an accurate diagnosis. Second, it can create long-term resentment of medical care in general. To illustrate, he cited a recent incident that occurred when he was sitting at an outdoor cafe with a friend. “We were just sitting there, when a man came up to us, and said ‘You are the doctor who gave me that shot!’” he recalled.

“He picked me out of the crowd, and just walked right up.” It had been two years since the man had been seen by Dr. Zeller, “but obviously he had been carrying this around,” he said. For a few moments, Dr. Zeller feared he was going to take a punch in broad daylight in front of his friend at the hands of his former patient. Instead he relied on his usual approach of verbal de-escalation and therapeutic alliance, and the man backed down. They both became amicable. “He ended up shaking my hand,” Dr. Zeller said.

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