Use of sedatives and restraints for treatment of agitation in the emergency department

An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department

We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice

OBJECTIVES

Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED.

DESIGN

Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events.

SETTING

Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital.

PARTICIPANTS

We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints.

RESULTS

Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions.

CONCLUSIONS

Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.

A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

Abstract

Background

Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation.

Methods

We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model.

Results

The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop.

Conclusions

Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07472-x.

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

IMPORTANCE

Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED.

OBJECTIVE

To characterize how individuals experience episodes of physical restraint during their ED visits.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018.

MAIN OUTCOMES AND MEASURES

Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED.

RESULTS

Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being.

CONCLUSIONS AND RELEVANCE

In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.