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Flaws D, Patterson S, Bagshaw T, Boon K, Kenardy J, Sellers D, Tronstad O. Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity. Nurs Open 2023; 10:7106-7117. [PMID: 37443430 PMCID: PMC10563417 DOI: 10.1002/nop2.1935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/22/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
AIM To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness. DESIGN & METHODS A discursive paper, drawing on clinical experience and research of the authors and current literature. RESULTS Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients. RELEVANCE TO CLINICAL PRACTICE ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care. PATIENT AND PUBLIC INVOLVEMENT This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.
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Affiliation(s)
- Dylan Flaws
- Caboolture HospitalCabooltureQueenslandAustralia
- Critical Care Research GroupThe Prince Charles HospitalChermsideQueenslandAustralia
- Queensland University of TechnologyBrisbane CityQueenslandAustralia
| | - Sue Patterson
- Critical Care Research GroupThe Prince Charles HospitalChermsideQueenslandAustralia
- School of DentistryUniversity of QueenslandBrisbane CityQueenslandAustralia
| | - Todd Bagshaw
- Caboolture HospitalCabooltureQueenslandAustralia
- The Prince Charles HospitalChermsideQueenslandAustralia
| | - Kym Boon
- Caboolture HospitalCabooltureQueenslandAustralia
| | - Justin Kenardy
- School of PsychologyUniversity of QueenslandBrisbane CityQueenslandAustralia
- Jamieson Trauma InstituteRoyal Brisbane and Women's HospitalHerstonQueenslandAustralia
| | - David Sellers
- The Prince Charles HospitalChermsideQueenslandAustralia
| | - Oystein Tronstad
- Critical Care Research GroupThe Prince Charles HospitalChermsideQueenslandAustralia
- The Prince Charles HospitalChermsideQueenslandAustralia
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Wong AH, Ray JM, Cramer LD, Brashear T, Eixenberger C, McVaney C, Haggan J, Sevilla M, Costa DS, Parwani V, Ulrich A, Dziura JD, Bernstein SL, Venkatesh AK. Design and Implementation of an Agitation Code Response Team in the Emergency Department. Ann Emerg Med 2022; 79:453-464. [PMID: 34863528 PMCID: PMC9038629 DOI: 10.1016/j.annemergmed.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.
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Affiliation(s)
- Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica M. Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanie Haggan
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Mark Sevilla
- Adult Emergency Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Donald S. Costa
- Department of Protective Services, Yale-New Haven Hospital, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James D. Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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Adams AMN, Chamberlain D, Grønkjær M, Thorup CB, Conroy T. Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review. Aust Crit Care 2021; 35:454-465. [PMID: 34373173 DOI: 10.1016/j.aucc.2021.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role. OBJECTIVES The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU. METHODS A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715. RESULTS Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues. CONCLUSIONS This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.
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Affiliation(s)
- Anne Mette N Adams
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia.
| | - Diane Chamberlain
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
| | - Mette Grønkjær
- Alborg University Hospital & Department of Clinical Medicine, Aalborg University, Denmark
| | - Charlotte Brun Thorup
- Department of Intensive Care and Clinical Nursing Research Unit, Aalborg University Hospital, Denmark
| | - Tiffany Conroy
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
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Schneider A, Mullinax S, Hall N, Acheson A, Oliveto AH, Wilson MP. Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials. Am J Emerg Med 2020; 46:193-199. [PMID: 33071100 DOI: 10.1016/j.ajem.2020.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Severely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings. OBJECTIVES The objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation. METHODS This review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool. RESULTS Eight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects. CONCLUSIONS Existing trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.
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Affiliation(s)
- Allison Schneider
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samuel Mullinax
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Nathanael Hall
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Ashley Acheson
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med 2020; 75:136-145. [PMID: 31563402 PMCID: PMC7945005 DOI: 10.1016/j.annemergmed.2019.07.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.
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Affiliation(s)
- Christina Shenvi
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC.
| | - Maura Kennedy
- Massachusetts General Hospital Department of Emergency Medicine and Harvard Medical School, Boston, MA
| | - Charles A Austin
- Department of Internal Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, AR
| | - Michael Gerardi
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ; Coalition on Psychiatric Emergencies
| | - Sandy Schneider
- American College of Emergency Physicians, Irving, TX; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX; Hofstra Northwell School of Medicine, Hempstead, NY
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Mullinax S, Shokraneh F, Wilson MP, Adams CE. Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials. J Emerg Med 2017; 53:524-529. [PMID: 28739149 DOI: 10.1016/j.jemermed.2017.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/04/2017] [Accepted: 04/25/2017] [Indexed: 10/24/2022]
Abstract
BACKGROUND Understanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies. OBJECTIVE The objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations for the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients. METHODS The Cochrane Schizophrenia Group's Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review. RESULTS Two oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychotics were similarly effective to intramuscular first-generation antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles. CONCLUSIONS This scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.
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Affiliation(s)
- Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) Lab, Little Rock, Arkansas
| | - Farhad Shokraneh
- Neurosciences Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran; Cochrane Schizophrenia Group, Institute of Mental Health - University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom
| | - Michael P Wilson
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) Lab, Little Rock, Arkansas; Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Clive E Adams
- Cochrane Schizophrenia Group, Institute of Mental Health - University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom
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Verhaltensbezogene Notfälle bei Erwachsenen. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Verhaltensbezogene Notfälle bei Erwachsenen. Abklärung und Behandlung. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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