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Agboola IK, Rosenberg A, Robinson L, Brashear TK, Eixenberger C, Shah D, Pavlo AJ, Im DD, Ray JM, Coupet E, Wong AH. A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department. Ann Emerg Med 2024; 83:108-119. [PMID: 37855791 PMCID: PMC10843036 DOI: 10.1016/j.annemergmed.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
STUDY OBJECTIVE Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.
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Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, NorthShore University Health System, Evanston, Illinois; Department of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alana Rosenberg
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut
| | - Leah Robinson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Taylor K Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica M Ray
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
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Thiessen MEW, Godwin SA, Hatten BW, Whittle JA, Haukoos JS, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med 2024; 83:e1-e30. [PMID: 38105109 DOI: 10.1016/j.annemergmed.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
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3
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Allen PJ, Johanson KE, Reveles KR, Neff LA, Lock AE. Comparison of Droperidol and Midazolam Versus Haloperidol and Lorazepam for Acute Agitation Management in the Emergency Department. Ann Pharmacother 2023; 57:1367-1374. [PMID: 36999520 DOI: 10.1177/10600280231163192] [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] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute agitation accounts for up to 2.6% of visits to the emergency department (ED). To date, a standard of care for the management of acute agitation has not been established. Few studies have evaluated antipsychotic and benzodiazepine combinations. OBJECTIVE The purpose of this study was to evaluate effectiveness and safety of combination therapy for acute agitation with intramuscular (IM) droperidol and midazolam (D+M) compared with IM haloperidol and lorazepam (H+L) in patients in the ED. METHODS This was a single-center, retrospective medical record review of patients presenting to a large, academic ED with acute agitation from July 2020 through October 2021. The primary outcome was percentage of patients requiring additional agitation medication within 60 minutes of combination administration. Secondary outcomes included average time to repeat dose administration and average number of repeat doses required before ED discharge. RESULTS A total of 306 patients were included for analysis: 102 in the D+M group and 204 in the H+L group. Repeat dose within 60 minutes occurred in 7 (6.9%) and 28 (13.8%) patients in the D+M and H+L groups, respectively (P = 0.065). A total of 28.4% of D+M patients and 30.9% of H+L patients required any repeat dose during their ED visit. Time to repeat dose was 12 and 24 minutes in the D+M and H+L, respectively (P = 0.22). The adverse event rate was 2.9% in each group. CONCLUSION AND RELEVANCE IM D+M resulted in a lower rate of repeat doses of acute agitation medication compared with IM H+L, though this was not statistically significant. Both therapies were safe, and the adverse event rate was low.
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Affiliation(s)
- Patrick J Allen
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kendra E Johanson
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Luke A Neff
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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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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Khatri UG, Delgado MK, South E, Friedman A. Racial Disparities in the Management of Emergency Department Patients Presenting with Psychiatric Disorders. Ann Epidemiol 2022; 69:9-16. [DOI: 10.1016/j.annepidem.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/23/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
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Does ketamine provide a shorter time to sedation when compared to haloperidol and midazolam in the agitated ED patient? CAN J EMERG MED 2021; 24:133-134. [PMID: 34971446 PMCID: PMC8718593 DOI: 10.1007/s43678-021-00249-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
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7
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deSouza IS, Thode HC, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med 2021; 51:363-373. [PMID: 34823192 DOI: 10.1016/j.ajem.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). METHODS The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. RESULTS Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. CONCLUSIONS Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Pragati Shrestha
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Jessica Koos
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY, USA.
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Kennedy M, Koehl J, Gao J, Ciampa KA, Hayes BD, Camargo CA. Use of antipsychotic and sedative medications in older patients in the emergency department. J Am Geriatr Soc 2021; 70:731-742. [PMID: 34820831 DOI: 10.1111/jgs.17590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/04/2021] [Accepted: 10/19/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients. METHODS This was an observational study using data from the 2014-2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration. RESULTS Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05-6.80), dementia (aOR: 5.62; 95% CI: 2.44-12.94), and delirium (aOR: 7.33; 95% CI: 2.21-24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42-2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02-2.08), and female gender (aOR: 1.47; 95% CI: 1.08-1.99) and negatively associated with older age (age: 75-84; aOR: 0.67; 95% CI: 0.49-0.91; age: 85+; aOR: 0.63; 95% CI: 0.45-0.88; reference age: 65-74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission. CONCLUSION We identified patient- and facility-level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Koehl
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Ciampa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan D Hayes
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Toxicology, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med 2021; 78:788-795. [PMID: 34353650 DOI: 10.1016/j.annemergmed.2021.05.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/12/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. METHODS We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. RESULTS Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). CONCLUSION In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Bill Macewan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hong Qian
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Skye P Barbic
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada; Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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10
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Agboola IK, Coupet E, Wong AH. "The Coats That We Can Take Off and the Ones We Can't": The Role of Trauma-Informed Care on Race and Bias During Agitation in the Emergency Department. Ann Emerg Med 2021; 77:493-498. [PMID: 33579587 DOI: 10.1016/j.annemergmed.2020.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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11
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Muir-Cochrane E, Oster C, Grimmer K. Interrogating systematic review recommendations for effective chemical restraint. J Eval Clin Pract 2020; 26:1768-1779. [PMID: 32059065 DOI: 10.1111/jep.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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12
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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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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis. Australas Emerg Care 2020; 24:96-111. [PMID: 33046432 DOI: 10.1016/j.auec.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. AIMS To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. METHOD Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. RESULTS Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol. CONCLUSION 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia.
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, 44 Greenhill Rd, Wayville, South Australia, Australia
| | - Tarun Bastiampillai
- College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
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Rajagopal AB, Jasperse N, Osborn MB. Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2020; 5:SG1-SG231. [PMID: 37465326 PMCID: PMC10334446 DOI: 10.21980/j82h1r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/01/2020] [Indexed: 07/20/2023]
Abstract
Audience The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians. Introduction Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers. Educational Objectives By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability. Educational Methods Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients. Research Methods Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise. Results Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses. Discussion Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article. Topics Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.
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Affiliation(s)
| | - Nathan Jasperse
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Megan Boysen Osborn
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
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Sharifi A, Arsalani N, Fallahi-Khoshknab M, Mohammadi-Shahbolaghi F, Ebadi A. Iranian nurses' perceptions about using physical restraint for hospitalized elderly people: a cross-sectional descriptive-correlational study. BMC Geriatr 2020; 20:233. [PMID: 32631236 PMCID: PMC7339549 DOI: 10.1186/s12877-020-01636-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/01/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Using physical restraint (PR) for hospitalized elderly people is a major nursing challenge. It is associated with different physical and mental complications and ethical dilemmas, though many nurses still use it to ensure patient safety. Nurses' perceptions are one of the most important factors affecting PR use. This study aimed to evaluate Iranian nurses' perceptions about PR use for hospitalized elderly people. METHODS This cross-sectional descriptive-correlational study was conducted from July to December 2019. Participants were 270 hospital nurses who were purposively recruited from intensive care units and medical and surgical wards of three teaching hospitals in Kermanshah, Iran. Data were collected using a demographic questionnaire and the Perceptions of Restraint Use Questionnaire (PRUQ). The SPSS software (v. 23.0) was used for data analysis through the independent-sample t test, the one-way analysis of variance, and the multiple regression analysis. RESULTS The total mean score of PRUQ was 4.08 ± 0.12 in the possible range of 1-5. The most important reasons for PR use were to prevent patients from falling out of bed and to prevent them from pulling out catheters. The total mean score of PRUQ had significant relationship with participants' age, work experience, and history of receiving PR-related educations (P < 0.05), but had no significant relationship with their gender, educational degree, and affiliated hospital ward (P > 0.05). CONCLUSION This study suggests that nurses attach high importance to PR use for hospitalized elderly people. Healthcare policy-makers at national and hospital levels are recommended to provide nurses with PR-related educations in order to reduce the rate of PR-related complications.
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Affiliation(s)
- Azam Sharifi
- Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Narges Arsalani
- Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
| | | | | | - Abbas Ebadi
- Nursing School, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Wong AH, Ray JM, Auerbach MA, Venkatesh AK, McVaney C, Burness D, Chmura C, Saxa T, Sevilla M, Flood CT, Patel A, Whitfill T, Dziura JD, Yonkers KA, Ulrich A, Bernstein SL. Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department. BMJ Open 2020; 10:e036982. [PMID: 32606062 PMCID: PMC7328814 DOI: 10.1136/bmjopen-2020-036982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Emergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists. METHODS AND ANALYSIS Our proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Marc A Auerbach
- Department of Pediatrics and Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Danielle Burness
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher Chmura
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Thomas Saxa
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mark Sevilla
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Colin T Flood
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Amitkumar Patel
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Travis Whitfill
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Kimberly A Yonkers
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
- Departments of Psychiatry and Obstetrics & Gynecology, Yale University, New Haven, Connecticut, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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19
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Nambiar D, Pearce JW, Bray J, Stephenson M, Nehme Z, Masters S, Brink D, Smith K, Arendts G, Fatovich D, Bernard S, Haskins B, Grantham H, Cameron P. Variations in the care of agitated patients in Australia and New Zealand ambulance services. Emerg Med Australas 2019; 32:438-445. [PMID: 31840407 DOI: 10.1111/1742-6723.13431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/13/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the present study is to examine variations in paramedic care of the agitated patient, including verbal de-escalation, physical restraint and sedation, provided by ambulance services in Australia and New Zealand. METHODS To examine the care of agitated patients, we first identified and reviewed all clinical practice guidelines for the management of agitated patients in Australian and New Zealand ambulance services between September and November 2018. We then conducted a structured questionnaire to obtain further information on the training, assessment and care of agitated patients by the ambulance services. Two authors extracted the data independently, and all interpretations and results were reviewed and confirmed by relevant ambulance services. RESULTS There were 10 independent clinical practice guidelines for the care of agitated patients in the 10 ambulance services. All services reported training in the management of agitated patients, and two services used a validated tool to assess the level of agitation. All services used physical restraint, although six services required police presence to restrain the patient. All ambulance services used some form of sedation, typically divided into the management of mild to moderate, and severe agitation. The most common agent for sedation was midazolam, while ketamine was the most common agent for sedating severely agitated patients. The maximum dose was varied, and contraindications for sedating agents varied between services. CONCLUSIONS There were wide variations across the ambulance services in terms of the assessment of agitation, as well as the use of physical restraint and sedation.
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Affiliation(s)
- Dhanya Nambiar
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James W Pearce
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Ziad Nehme
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Stacey Masters
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Deon Brink
- St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Glenn Arendts
- Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | | | | | - Hugh Grantham
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
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Characteristics and Severity of Agitation Associated With Use of Sedatives and Restraints in the Emergency Department. J Emerg Med 2019; 57:611-619. [DOI: 10.1016/j.jemermed.2019.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/07/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
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21
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Maas MS, Moeller KE, Melton BL. Determination of combination therapy prescribing patterns for the treatment of acute agitation in psychiatric patients: A regression model of patient diagnoses and demographics. Ment Health Clin 2019; 9:298-303. [PMID: 31534870 PMCID: PMC6728119 DOI: 10.9740/mhc.2019.09.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Guidelines for the treatment of acute agitation typically recommend monotherapy with an antipsychotic or a benzodiazepine, but combination therapy is frequently used in practice. We created a regression model to identify which factors lead to the prescribing of combination therapy for acute agitation on a psychiatry unit. Methods We collected retrospective data from hospitalized patients in the psychiatry unit. An a priori alpha of 0.05 was used for binary logistic regression models to determine if and how the number of prescribed medications for acute agitation was influenced by: age, sex, race, cardiovascular comorbidities, and psychiatric diagnoses. Results We identified 1998 encounters from 1200 patients. Patients are significantly more likely to be prescribed combination therapy if they are young, male, and of non-white race or have a diagnosis of central nervous system stimulant use, hallucinogen use, depression, bipolar, cluster B personality, or psychosis. Patients are significantly more likely to be prescribed monotherapy if they have cardiovascular comorbidity or have neurocognitive disorder. Discussion Several demographic or diagnostic factors predict combination therapy prescribing. Acute agitation guidelines should be reviewed to include more clear instructions on combination therapy use.
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE, Graudins A, Keijzers G, Kulawickrama S, Thom O, Lawton L, Furyk J, Finucci D, Holdgate A, Watkins G, Jordan P. Management of behavioural emergencies: a prospective observational study in Australian emergency departments. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
| | - David McD. Taylor
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department Austin Health Melbourne Australia
| | - David C. M. Kong
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
- Pharmacy Department Ballarat Health Services Ballarat Australia
| | - Jonathan C. Knott
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
| | | | - Andis Graudins
- Emergency Department Monash Health Melbourne Australia
- Department of Medicine, Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Gerben Keijzers
- Emergency Department Gold Coast University Hospital Gold Coast Australia
- School of Medicine Bond University Gold Coast Australia
- School of Medicine Griffith University Gold Coast Australia
| | | | - Ogilvie Thom
- Emergency Department Nambour General Hospital Nambour Australia
| | - Luke Lawton
- Emergency Department The Townsville Hospital Townsville Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Australia
| | - Daniel Finucci
- Emergency Department Liverpool Hospital Sydney Australia
| | - Anna Holdgate
- Emergency Department Liverpool Hospital Sydney Australia
| | - Gina Watkins
- Emergency Department Sutherland Hospital Sydney Australia
| | - Peter Jordan
- Emergency Department The Northern Hospital Melbourne Australia
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Wong AH, Crispino L, Parker J, McVaney C, Rosenberg A, Ray JM, Whitfill T, Iennaco JD, Bernstein SL. Use of sedatives and restraints for treatment of agitation in the emergency department. Am J Emerg Med 2018; 37:1376-1379. [PMID: 30598374 DOI: 10.1016/j.ajem.2018.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America.
| | - Lauren Crispino
- Rowan University School of Osteopathic Medicine, Stratford, NJ, United States of America
| | - John Parker
- Medical College of Georgia, Augusta, GA, United States of America
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
| | - Alana Rosenberg
- Yale School of Public Health, New Haven, CT, United States of America
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Travis Whitfill
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, MacEwan W, Honer WG, Wong H, Barbic SP. Rapid agitation control with ketamine in the emergency department (RACKED): a randomized controlled trial protocol. Trials 2018; 19:651. [PMID: 30477544 PMCID: PMC6258312 DOI: 10.1186/s13063-018-2992-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/16/2018] [Indexed: 01/26/2023] Open
Abstract
Background The rapid control of patients presenting to the emergency department (ED) with psychomotor agitation and violent behavior is paramount for the safety of patients and ED staff. The use of intramuscular (IM) ketamine in the pre-hospital and ED settings has demonstrated promising preliminary results to provide rapid and safe behavioral control. A prospective, randomized controlled trial is required to measure the potential superiority of IM ketamine compared to current standard care (IM benzodiazepines plus antipsychotics). Methods This will be a parallel, prospective, randomized, controlled trial of 5 mg/kg IM ketamine compared to a combination of 5 mg IM midazolam and 5 mg IM haloperidol. The study will enroll approximately 184 patients, randomized equally to two study arms. There will be one study visit during which study medication will be administered and assessments will be completed. A follow-up safety visit will occur on day 3. The primary objective of this study is to compare IM ketamine to a combination of IM midazolam and haloperidol with regards to the time required for adequate behavioral control, in minutes, in patients presenting to the ED with psychomotor agitation and violent behavior, as measured by the Richmond Agitation-Sedation Scale (RASS). Discussion We present a novel study to determine whether ketamine is a rapid and safe option, compared to a combination of midazolam and haloperidol for the sedation of patients presenting to the ED with psychomotor agitation and violent behavior. To our knowledge, this study is the first randomized controlled trial to compare ketamine to current standard care for this indication. We have attempted to address numerous logistical issues with the design of this study including a waiver of consent, ensuring adequate blinding of outcome assessors, patient enrolment, and data monitoring. Trial registration Clinicaltrials.gov, NCT03375671. Registered on 18 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2992-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, Lion's Gate Hospital, 231 15th St E, North Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - William MacEwan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- School of Public Health and Epidemiology, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Skye P Barbic
- Department of Occupational Science and Occupational Therapy, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
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Heydari F, Gholamian A, Zamani M, Majidinejad S. Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial. Bull Emerg Trauma 2018; 6:292-299. [PMID: 30402516 PMCID: PMC6215072 DOI: 10.29252/beat-060404] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the efficacy and safety of intramuscular ketamine and haloperidol in sedation of severely agitated patients in emergency department (ED). Methods This randomized, double-blind clinical trial study was performed on agitated patients referring to two university educational hospitals. Patients were randomly assigned to receive intramuscular (IM) haloperidol (5 mg) or IM ketamine (4 mg/kg). The primary outcome was time to adequate sedation (AMSS ≤ +1). Secondary outcomes included the need for additional sedatives, required intubation, duration of hospitalization, and side effects. Results The 90 agitated patients were enrolled. The mean age was 30.37±7.36 years (range 18-56); 74% (67/90) were men. The mean time to adequate sedation in ketamine group (7.73 ± 4.71 minutes) was significantly lower than haloperidol group (11.42 ± 7.20 minutes) (p= 0.005). 15 minutes after intervention, the sedation score did not differ significantly in both groups (Ketamine:0.14 ± 0.59 vs. Haloperidol: 0.30 ± 0.60; p=0.167). The incidence of complications was not significantly different between groups. The physician's satisfaction from the patients' aggression control was significantly higher in ketamine group. Conclusion These data suggest ketamine may be used for short-term control of agitated patients, additional studies are needed to confirm if ketamine is safe in this patient population. Given rapid effective sedation and the higher physician satisfaction of ketamine in comparison to haloperidol, it may be considered as a safe and appropriate alternative to haloperidol.IRCT Code: IRCT20180129038549N5.
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Affiliation(s)
- Farhad Heydari
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Gholamian
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Zamani
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Majidinejad
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Wong AH, Taylor RA, Ray JM, Bernstein SL. Physical Restraint Use in Adult Patients Presenting to a General Emergency Department. Ann Emerg Med 2018; 73:183-192. [PMID: 30119940 DOI: 10.1016/j.annemergmed.2018.06.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/31/2018] [Accepted: 06/11/2018] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE The prevalence of agitation among emergency department (ED) patients is increasing. Physical restraints are routinely used to prevent self-harm and to protect staff, but are associated with serious safety risks. To date, characterization of physical restraint use in the emergency setting has been limited. We thus aim to describe restraint patterns in the general ED to guide future investigation in the management of behavioral disorders. METHODS We conducted a cross-sectional study of adult patients presenting to 5 adult EDs within a large regional health system for 2013 to 2015, and with a physical restraint order during their visit. We undertook descriptive analyses and cluster analysis to determine unique meaningful groups within our sample. RESULTS In 956,153 total ED visits, 4,661 patients (0.5%) had associated restraint orders, representing 3,739 unique patients. The median age was 47 years (interquartile range 32 to 59 years), 66.7% of patients were men, 61.9% had a psychiatric history, and 91.1% arrived by ambulance. For chief complaints, 33.7% were alcohol or drug use, 45.4% medical, 12.3% psychiatric, and 8.5% trauma. Cluster analysis identified 2 distinct cohorts. A younger, predominantly male population presented with alcohol or drug use, whereas an older group arrived with medical complaints. CONCLUSION Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED. Further characterization of causal links and safer practices to manage agitation for these vulnerable populations are needed.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - R Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
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Edlinger M, Welte AS, Yalcin-Siedentopf N, Kemmler G, Neymeyer F, Fleischhacker WW, Hofer A. Trends in pharmacological emergency treatment of patients suffering from schizophrenia over a 16-year observation period. Int Clin Psychopharmacol 2018; 33:197-203. [PMID: 29664808 DOI: 10.1097/yic.0000000000000220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients suffering from schizophrenia are often treated in locked psychiatric units because of psychomotor agitation, hostility and aggressive behavior, or suicidality. Because of legal conditions, investigations on these acutely ill patients are difficult, and many studies do not represent 'real-life psychiatry'. This retrospective survey was conducted at the Department of Psychiatry, Psychotherapy and Psychosomatics of the Medical University, Innsbruck, Austria. Data were collected from the records of all adult inpatients suffering from a schizophrenia spectrum disorder according to the International Classification of Diseases, 10th ed. (ICD-10) (F2x) who had been admitted to a locked unit in 1997, 2002, 2007, and 2012. In addition to demographic data, diagnoses at the time of admission, length of stay at the locked unit, and psychopharmacological treatment (3 h before and following admission) were recorded. The mean length of stay at a locked unit decreased significantly from 11.8±4.43 days (mean±SD) in 1997 to 8.5±12.96 days (mean±SD) in 2012. The use of antipsychotics decreased nonsignificantly from 1997 to 2012. Despite an increasing use of second compared with first-generation antipsychotic drugs over the course of time, haloperidol was the most frequently used single compound in all investigated years except 2012. The majority of medications were administered orally. The use of benzodiazepines did not change substantially over the course of time. All in all, pharmacological emergency treatment of patients suffering from schizophrenia spectrum disorders in locked units was in line with current treatment guidelines, which recommend the use of second-generation antipsychotic drugs, monotherapy, oral application, and cautious dosing.
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Affiliation(s)
- Monika Edlinger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
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Yap CYL, Hsueh YS(A, Knott JC, Taylor DM, Chan EW, Kong DCM. Economic Evaluation of Midazolam-Droperidol Combination, Versus Droperidol or Olanzapine for the Management of Acute Agitation in the Emergency Department: A Within-Trial Analysis. PHARMACOECONOMICS - OPEN 2018; 2:141-151. [PMID: 29623620 PMCID: PMC5972118 DOI: 10.1007/s41669-017-0047-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The combination of midazolam and droperidol has proven superior to droperidol or olanzapine monotherapy in the management of acute agitation in emergency departments (EDs). OBJECTIVE This is the first economic analysis to evaluate the cost-benefit and cost effectiveness of the midazolam-droperidol combination compared with droperidol or olanzapine for the management of acute agitation in EDs. METHODS This analysis used data derived from a randomised, controlled, double-blind clinical trial conducted in two metropolitan Australian EDs between October 2014 and August 2015. The economic evaluation was from the perspective of Australian public hospital EDs. The main outcomes included agitation management time and the agitation-free time gained. Sensitivity analyses were undertaken. RESULTS The midazolam-droperidol combination was the least costly regimen (Australian dollars [AU$]46.25 per patient) compared with the droperidol and olanzapine groups (AU$92.18 and AU$110.45 per patient, respectively). The main cost driver for all groups was the cost of the labour required during the initial adequate sedation. The combination afforded an additional 10-13 min of mean agitation-free time gained, which can be translated to additional savings of AU$31.24-42.60 per patient compared with the droperidol and olanzapine groups. The benefit-cost ratio for the midazolam-droperidol combination was 12.2:1.0, or AU$122,000 in total benefit for every AU$10,000 spent on management of acute agitation. Sensitivity analyses over key variables indicated these results were robust. CONCLUSIONS The midazolam-droperidol combination may be a cost-saving and dominant cost-effective regimen for the treatment of acute agitation in EDs as it is more effective and less costly than either droperidol or olanzapine monotherapy.
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Affiliation(s)
- Celene Y. L. Yap
- Centre for Medicine Use and Safety, Monash University, 381 Royal Parade, Parkville, VIC 3052 Australia
| | - Ya-seng (Arthur) Hsueh
- Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, VIC 3053 Australia
| | - Jonathan C. Knott
- Emergency Department, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3052 Australia
| | - David McD Taylor
- Emergency Department, Austin Health, Studley Road, Heidelberg, VIC 3084 Australia
| | - Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong
| | - David C. M. Kong
- Centre for Medicine Use and Safety, Monash University, 381 Royal Parade, Parkville, VIC 3052 Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond St N, Ballarat, VIC 3350 Australia
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Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department. Jt Comm J Qual Patient Saf 2018; 44:279-292. [PMID: 29759261 DOI: 10.1016/j.jcjq.2017.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. METHODS A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. RESULTS Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. CONCLUSION Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.
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Raab M, Lizarondo L, Brook C. Effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:805-810. [PMID: 29634503 DOI: 10.11124/jbisrir-2017-003574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to identify, evaluate and synthesize evidence on the effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation.
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Affiliation(s)
- Martin Raab
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- ACT Ambulance Service, Canberra, Australia
| | - Lucylynn Lizarondo
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy. J Emerg Med 2018; 54:364-374. [DOI: 10.1016/j.jemermed.2017.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 11/22/2022]
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