1
|
Jivalagian P, Gettel CJ, Smith CM, Robinson L, Brinker M, Shah D, Kumar A, Faustino IV, Nath B, Chang-Sing E, Taylor RA, Kennedy M, Hwang U, Wong AH. Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department. Am J Geriatr Psychiatry 2024:S1064-7481(24)00398-1. [PMID: 39054237 DOI: 10.1016/j.jagp.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.
Collapse
Affiliation(s)
- Patelle Jivalagian
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Cameron J Gettel
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Colin M Smith
- Hubert-Yeargan Center for Global Health (CMS), Duke University, Durham, NC
| | - Leah Robinson
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine (MB), New Haven, CT
| | - Dhruvil Shah
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Anusha Kumar
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Isaac V Faustino
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Bidisha Nath
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Erika Chang-Sing
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - R Andrew Taylor
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT; Department of Biomedical Informatics and Data Science (RAT), Yale School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine (MK), Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine (MK), Harvard Medical School, Boston, MA
| | - Ula Hwang
- Department of Emergency Medicine (UH), New York University Grossman School of Medicine, New York, NY; Geriatric Research Education and Clinical Center (UH), James J. Peters VAMC, Bronx, NY
| | - Ambrose H Wong
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT.
| |
Collapse
|
2
|
Paul FA, Ganie AUR, Dar DR, Saikia P, Banerjee I. Exploring psychiatric patient restraints: Balancing safety, ethics, and patient rights in mental healthcare. Asian J Psychiatr 2024; 96:104051. [PMID: 38643681 DOI: 10.1016/j.ajp.2024.104051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/26/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024]
Abstract
Restraint, often linked with limiting an individual's freedom of movement, has become a focal point of extensive discussion and evaluation within the realm of mental healthcare. Striking a delicate balance between ensuring individual safety and minimizing reliance on restraint methods poses a significant challenge. In mental health inpatient settings, the prevalent forms of restraint encompass physical, chemical, environmental, and psychological methods. Paradoxically, the consequences of employing restraint can be severe, ranging from injuries and cognitive decline to sedation and, in extreme cases, fatalities. This paper seeks to offer a nuanced exploration of the landscape surrounding psychiatric patient restraints, considering both global perspectives and specific insights from the Indian context. The guidelines outlined in India's Mental Healthcare Act of 2017, which governs the use of restraint on individuals suffering with mental illnesses, are also examined in detail.
Collapse
Affiliation(s)
- Fayaz Ahmad Paul
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Aasim Ur Rehman Ganie
- Sharda School of Humanities and Social Sciences, Sharda University, Knowledge Park-3, Greater Noida 201310, India.
| | - Danishwar Rasool Dar
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Priyanka Saikia
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| | - Indrajeet Banerjee
- Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India.
| |
Collapse
|
3
|
Aguglia A, Corsini GP, Berardelli I, Berti A, Conio B, Garbarino N, Gnecco GB, Magni C, Venturini E, Costanza A, Amerio A, Amore M, Serafini G. Mechanical Restraint in Inpatient Psychiatric Unit: Prevalence and Associated Clinical Variables. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1847. [PMID: 37893565 PMCID: PMC10607962 DOI: 10.3390/medicina59101847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: mechanical restraint (MR) is a controversial issue in emergency psychiatry and should be better studied to implement other alternative therapeutic interventions. The aim of this study was to estimate the prevalence of MR in an Italian psychiatric unit and identify the sociodemographic and clinical characteristics as well as the pharmacological pattern associated with MR. Materials and Methods: all subjects (N = 799) consecutively admitted to an Italian psychiatric inpatient unit were recruited. Several sociodemographic and clinical characteristics were recorded. Results: The prevalence of MR was 14.1%. Males, a younger age, and a single and migrant status were associated with the MR phenomenon. MR was more prevalent in patients affected by other diagnoses and comorbid illicit substance use, in patients with aggressive behaviors, and those that were involuntary admitted, leading significantly to hospitalization over 21 days. Furthermore, the patients that underwent MR were taking a lower number of psychiatric medications. Conclusions: Unfortunately, MR is still used in emergency psychiatry. Future research should focus on the dynamics of MR development in psychiatry, specifically considering ward- and staff-related factors that could help identify a more precise prevention and alternative intervention strategies.
Collapse
Affiliation(s)
- Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Policlinico San Martino, 16132 Genoa, Italy; (G.P.C.); (B.C.)
| | - Giovanni Pietro Corsini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Policlinico San Martino, 16132 Genoa, Italy; (G.P.C.); (B.C.)
| | - Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
| | - Andrea Berti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Benedetta Conio
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Policlinico San Martino, 16132 Genoa, Italy; (G.P.C.); (B.C.)
| | - Nicolò Garbarino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Giovanni Battista Gnecco
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Caterina Magni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Enrico Venturini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Alessandra Costanza
- Department of Psychiatry, Adult Psychiatry Service, University Hospitals of Geneva (HUG), 1207 Geneva, Switzerland
- Department of Psychiatry, Faculty of Biomedical Sciences, University of Italian Switzerland (USI), 6900 Lugano, Switzerland
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), 1211 Geneva, Switzerland
| | - Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Policlinico San Martino, 16132 Genoa, Italy; (G.P.C.); (B.C.)
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16132 Genoa, Italy; (A.A.); (A.B.); (N.G.); (G.B.G.); (C.M.); (E.V.); (A.A.); (M.A.); (G.S.)
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Policlinico San Martino, 16132 Genoa, Italy; (G.P.C.); (B.C.)
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
Collapse
Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
| |
Collapse
|
6
|
Sullivan N, Chen C, Siegel R, Ma Y, Pourmand A, Montano N, Meltzer A. Ketamine for emergency sedation of agitated patients: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:655-661. [DOI: 10.1016/j.ajem.2019.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 12/28/2022] Open
|
7
|
Ziaei M, Massoudifar A, Rajabpour-Sanati A, Pourbagher-Shahri AM, Abdolrazaghnejad A. Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2018; 3:e7. [PMID: 31172118 PMCID: PMC6548084 DOI: 10.22114/ajem.v0i0.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
CONTEXT The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods. EVIDENCE ACQUISITION This review was conducted by searching "Violence," "Aggression," and "workplace violence" keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review. RESULTS Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint. CONCLUSION In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.
Collapse
Affiliation(s)
- Maryam Ziaei
- Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Ali Massoudifar
- Department of Psychiatry, School of Medicine, Hormozgan University of Medical Sciences, Bandarabbas, Iran
| | | | | | - Ali Abdolrazaghnejad
- Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| |
Collapse
|
8
|
Affiliation(s)
- Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
| | - Christopher B Colwell
- Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Andrew Grock
- Division of Emergency Medicine Greater Los Angeles VA Healthcare System, and the David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
9
|
Abstract
Violence against health care workers is an unfortunately common event. Because of several inherent factors, emergency departments are particularly vulnerable. Once an incident occurs, it often goes unreported and leads to both physical and mental trauma. Health care workers should learn to recognize the cues that patients are escalating toward violence and be familiar with various options for sedating agitated patients. If sedation is not successful, physical restraint may become necessary. There are measures that can be taken that may help minimize the likelihood of violence toward health care workers. These measures include legislation, physical design, and increased security.
Collapse
|
10
|
|
11
|
Petrik ML, Betz ME, Olson-Madden JH, Davidson C, Allen MH. Identification, Assessment, and Management of Suicide Risk in Emergency Departments: Significant Updates in Research and Practice. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
12
|
Cunha M, André S, Bica I, Ribeiro O, Dias A, Andrade A. Chemical and Physical Restraint of Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.sbspro.2016.02.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
13
|
Affiliation(s)
- Marian E Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO.
| | - Edwin D Boudreaux
- Departments of Emergency Medicine, Psychiatry, and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| |
Collapse
|
14
|
Deal N, Hong M, Matorin A, Shah AA. Stabilization and Management of the Acutely Agitated or Psychotic Patient. Emerg Med Clin North Am 2015; 33:739-52. [DOI: 10.1016/j.emc.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
15
|
Deitch K, Rowden A, Damiron K, Lares C, Oqroshidze N, Aguilera E. Unrecognized hypoxia and respiratory depression in emergency department patients sedated for psychomotor agitation: pilot study. West J Emerg Med 2015; 15:430-7. [PMID: 25035749 PMCID: PMC4100849 DOI: 10.5811/westjem.2014.2.19102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 11/22/2013] [Accepted: 02/03/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED. METHODS Adult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of ≥50 mmHg, a change of 10% above or below baseline, or a loss of waveform for ≥15 seconds. Hypoxia was defined as a SpO2 of ≤93% for ≥15 seconds. RESULTS We enrolled 59 patients, and excluded 9 because of ≥35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42-69%); the median number of events was 2 (range 1-6). Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29-55%); the median number of events was 2 (range 1-5). Nineteen (19/21) (90%, 95% CI 71-97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56-91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68-98%) and specificity 69% (95% CI: 49-84%). Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse event. CONCLUSION About half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians.
Collapse
Affiliation(s)
- Kenneth Deitch
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Adam Rowden
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Kathia Damiron
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Claudia Lares
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Nino Oqroshidze
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Elizabeth Aguilera
- Einstein Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Uldall K, Williams BL, Dunn JD, Blackmore CC. Association between combative behavior requiring intervention and delirium in hospitalized patients. J Hosp Med 2014; 9:658-62. [PMID: 25130651 DOI: 10.1002/jhm.2247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 07/02/2014] [Accepted: 07/19/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND We hypothesized that delirium contributes to combative behavior requiring intervention in hospitalized patients. Delirium identification would therefore potentially provide an opportunity for prevention and early identification of patients at risk, thereby improving safety for patients and staff. OBJECTIVE To determine whether delirium is associated with combative behavior requiring intervention in a general hospital population. DESIGN Case control study. SETTING A 336-bed, nonuniversity, teaching hospital serving adults in the Pacific Northwest. PATIENTS One hundred twenty consecutive hospitalized patients with combative behavior requiring intervention compared to 159 randomly selected inpatient control subjects, all from 2011. INTERVENTION Bivariate statistics were used to compare demographics; diagnoses; presence of delirium, dementia, substance use, other psychiatric diagnosis; medications; hospital length of stay; and discharge disposition. We used stepwise logistic regression to determine the association of combative behavior requiring intervention with delirium after adjustment for covariates. RESULTS Delirium preceding the combative behavior was present in 50% (60/120) of patients with combative behavior requiring intervention compared to 16% (26/159) of controls (P < 0.001). Combative-behavior patients were hospitalized longer (9.4 vs 4.5 days, P < 0.001), and were more likely to be discharged to a skilled nursing facility (26%, 31/120) or to leave against medical advice (10%, 12/120, P < 0.001). Delirium was strongly associated with combative behavior requiring intervention, after adjustment (odds ratio: 3.8, 95% confidence interval: 2.0-7.3, P < 0.001). CONCLUSION Delirium is strongly associated with combative behavior requiring intervention, which poses a significant safety risk for patients and staff.
Collapse
Affiliation(s)
- Karina Uldall
- Department of Psychiatry, Virginia Mason Medical Center, Seattle, Washington
| | | | | | | |
Collapse
|
17
|
Abstract
Agitation is a chief complaint that causes many children and adolescents to present to emergency medical attention. There are many reasons for acute agitation, including toxicologic, neurologic, infectious, metabolic, and functional disorders. At times it may be necessary to pharmacologically treat the agitation to prevent harm to the patient, caregivers, or hospital staff. However, one should always be mindful that the differential diagnosis is broad, and a complete although timely assessment with targeted testing must be done before concluding that the agitation is rooted solely in nonorganic causes. There are various pharmacologic choices for the treatment of agitation, and they will be reviewed here. While treatment of agitation may be necessary to keep the patient as well as staff safe, as well as to facilitate medical evaluation in some cases, care must be taken to treat the patient with compassion, never using pharmacologic treatment for reasons of punishment or staff convenience. The focus is on the pharmacologic management of acute agitation of patients in the pediatric age group, in the context of a full evaluation for possible nonfunctional causes of agitation. Goals, risks, and benefits of medication use will be reviewed.
Collapse
|
18
|
Georgieva I, Vesselinov R, Mulder CL. Early detection of risk factors for seclusion and restraint: a prospective study. Early Interv Psychiatry 2012; 6:415-22. [PMID: 22277018 DOI: 10.1111/j.1751-7893.2011.00330.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint. METHODS Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis. RESULTS The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%). CONCLUSION Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.
Collapse
Affiliation(s)
- Irina Georgieva
- Research Center O3, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands.
| | | | | |
Collapse
|
19
|
McGraw M, McGraw L. Bath salts: not as harmless as they sound. J Emerg Nurs 2012; 38:582-8. [PMID: 23040164 DOI: 10.1016/j.jen.2012.07.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 07/27/2012] [Accepted: 07/28/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Mark McGraw
- Critical Care TransportTeam, Christiana Care Health System, Newark, DE, USA.
| | | |
Collapse
|
20
|
Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med 2012; 43:829-35. [PMID: 22698827 DOI: 10.1016/j.jemermed.2012.01.064] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 09/26/2011] [Accepted: 01/16/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Care of the psychiatric patient in the Emergency Department (ED) is evolving. As with other disease states, there are a number of pitfalls that complicate the care of the psychiatric patient. OBJECTIVE The purpose of this article is to update Emergency Physicians concerning the pitfalls in caring for the psychiatric patient, and possible solutions to deal with these pitfalls. DISCUSSION The article will address the burden of the psychiatric patient, staff attitudes, medical clearance process, treatment of the agitated patient, suicidal patients, and admission decisions. CONCLUSIONS Alternative care resources, collaboration with Psychiatry, staff education, improvement in the medical clearance process, proper use of restraint and seclusion, and appropriate choice of medication for agitated patients can help avoid some of the top pitfalls in the care of the psychiatric patient in the ED.
Collapse
Affiliation(s)
- Leslie S Zun
- Department of Emergency Medicine, Mount Sinai Hospital and Chicago Medical School, Chicago, Illinois 60608, USA
| |
Collapse
|
21
|
Abstract
This study examined patients' preferences for coercive methods and the extent to which patients' choices were determined by previous experience, demographic, clinical and intervention-setting variables. Before discharge from closed psychiatric units, 161 adult patients completed a questionnaire. The association between patients' preferences and the underlying variables was analyzed using logistic regression. We found that patients' preferences were mainly defined by earlier experiences: patients without coercive experiences or who had had experienced seclusion and forced medication, favoured forced medication. Those who had been secluded preferred seclusion in future emergencies, but only if they approved its duration. This suggests that seclusion, if it does not last too long, does not have to be abandoned from psychiatric practices. In an emergency, however, most patients prefer to be medicated. Our findings show that patients' preferences cannot guide the establishment of international uniform methods for managing violent behaviour. Therefore patients' individual choices should be considered.
Collapse
|
22
|
Hopper SM, Babl FE, Stewart CE, Woo JW. Aggression management in a children's hospital setting. Med J Aust 2012; 196:198-201. [DOI: 10.5694/mja11.10257] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sandy M Hopper
- Murdoch Childrens Research Institute, University of Melbourne, Melbourne, VIC
- Royal Children's Hospital, Melbourne, VIC
| | - Franz E Babl
- Murdoch Childrens Research Institute, University of Melbourne, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | | | - Jia Wei Woo
- University of Melbourne, Melbourne, VIC
- Eastern Health, Melbourne, VIC
| |
Collapse
|
23
|
|