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Tan E, Beck S, Haskell L, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments. Emerg Med Australas 2022; 34:943-953. [PMID: 35644989 PMCID: PMC9796118 DOI: 10.1111/1742-6723.14022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children. METHODS A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort. RESULTS Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed. CONCLUSIONS Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentNorth Shore HospitalAucklandNew Zealand,Emergency DepartmentWaitakere HospitalAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Liggins Institute, The University of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
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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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A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments. Ann Emerg Med 2019; 75:206-217. [PMID: 31474478 DOI: 10.1016/j.annemergmed.2019.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature. METHODS We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included. RESULTS Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent. CONCLUSION Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.
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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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Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon. Med J Islam Repub Iran 2018; 32:60. [PMID: 30175086 PMCID: PMC6113581 DOI: 10.14196/mjiri.32.60] [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: 11/16/2017] [Indexed: 01/29/2023] Open
Abstract
Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians' opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians' preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies.
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Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2017; 69:318-326.e1. [DOI: 10.1016/j.annemergmed.2016.07.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/18/2022]
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Tandon A, Wang M, Roe KC, Patel S, Ghahramani N. Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios. Clin Kidney J 2016; 9:611-5. [PMID: 27478607 PMCID: PMC4957715 DOI: 10.1093/ckj/sfw031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/08/2016] [Indexed: 01/04/2023] Open
Abstract
Background There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral. Methods A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant. Results Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant. Conclusions The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.
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Affiliation(s)
- Ankita Tandon
- Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Ming Wang
- Department of Public Health Sciences , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Kevin C Roe
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Surju Patel
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Nasrollah Ghahramani
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, Baldaçara L, San L, McAllister-Williams RH, Fountoulakis KN, Courtet P, Naber D, Chan EW, Fagiolini A, Möller HJ, Grunze H, Llorca PM, Jaffe RL, Yatham LN, Hidalgo-Mazzei D, Passamar M, Messer T, Bernardo M, Vieta E. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry 2016; 17:86-128. [PMID: 26912127 DOI: 10.3109/15622975.2015.1132007] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
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Affiliation(s)
- Marina Garriga
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Isabella Pacchiarotti
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Siegfried Kasper
- c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Michael H Allen
- e University of Colorado Depression Center , Denver , CO 80045 , USA
| | - Gustavo Vázquez
- f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina
| | | | - Luis San
- h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain
| | - R Hamish McAllister-Williams
- i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Konstantinos N Fountoulakis
- j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Philippe Courtet
- k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France
| | - Dieter Naber
- l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Esther W Chan
- m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China
| | - Andrea Fagiolini
- n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy
| | - Hans Jürgen Möller
- o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany
| | - Heinz Grunze
- p Paracelsus Medical University , Salzburg , Austria
| | - Pierre Michel Llorca
- q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France
| | | | - Lakshmi N Yatham
- s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada
| | - Diego Hidalgo-Mazzei
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Marc Passamar
- t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France
| | - Thomas Messer
- u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany
| | - Miquel Bernardo
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Eduard Vieta
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
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Chan EWY, Tang C, Lao KSJ, Ling Pong L, Tsui MSH, Ho HF, Wong GCK, Kong DCM, McD Taylor D, Knott JC, Wong ICK. Management of acute agitation in Hong Kong and comparisons with Australasia. Emerg Med Australas 2015; 27:542-548. [PMID: 26635127 DOI: 10.1111/1742-6723.12499] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 06/16/2015] [Accepted: 08/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Little is known about the use of sedation drugs for the management of acute agitation in Hong Kong's Accident and Emergency Departments (AEDs) and how it compares with Australasian practice. OBJECTIVE The aim of this study was to determine drug preferences, clinicians' perceived confidence in management, barriers/gaps in training and perceived usefulness of existing clinical practice guidelines (CPGs) in Hong Kong. METHOD A validated questionnaire was used, with case vignettes typical of patients presenting to AEDs with acute agitation. The questionnaire was distributed by hand to all trainees and fellows of the Hong Kong College of Emergency Medicine (HKCEM). Two reminders were sent. RESULTS Of 483 HKCEM members, 280 (58.0% [95% CI 53.5-62.3]) responded. For monotherapy, 46.8% (95% CI 41.0-52.6) of respondents chose haloperidol to manage the undifferentiated patient, followed by midazolam (33.9%, 95% CI 28.6-39.7) and diazepam (13.9%, 95% CI 10.4-18.5). Most respondents (83.6%, 95% CI 78.8-87.5) would not administer combination therapy. Respondents were confident in managing agitation overall. The lack of local/institutional CPGs (55.7%, 95% CI 49.9-61.4) was perceived as an important barrier. Institutional guidelines were considered the most useful CPGs (66.4%, 95% CI 60.7-71.7). Most respondents (72.9%, 95% CI 67.4-77.7) perceived a HKCEM endorsed CPG would be useful. CONCLUSION Haloperidol and benzodiazepines are frequently used as monotherapy for the management of acute agitation in Hong Kong's AEDs. Management in Hong Kong differs from Australasian practice in that combination therapy is less common and clinicians' choice of sedation drugs are less variable overall. Results suggest that future work on CPG development and training regarding the safe use of combination therapy would be well received.
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Affiliation(s)
- Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Cedric Tang
- School of Pharmacy, University College London, London, UK
| | - Kim Shi Jian Lao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong
| | - Leung Ling Pong
- Emergency Medicine Unit, , The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Hiu Fai Ho
- Department of Accident and Emergency, Queen Elizabeth Hospital, King's Park, Hong Kong
| | - Gordon Chi Keung Wong
- Department of Accident and Emergency, Queen Elizabeth Hospital, King's Park, Hong Kong
| | - David Chee Ming Kong
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
| | - Jonathan C Knott
- Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong.,Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
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Prescribing preferences in rapid tranquillisation: a survey in Belgian psychiatrists and emergency physicians. BMC Res Notes 2015; 8:218. [PMID: 26043843 PMCID: PMC4467636 DOI: 10.1186/s13104-015-1172-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 05/13/2015] [Indexed: 01/12/2023] Open
Abstract
Background The pharmacotherapeutic management of agitation is a common clinical challenge. Pharmacotherapy is frequently used, the use of published guidelines is not known. The purpose of this study was twofold; to describe the prescribing patterns of psychiatrists and emergency physicians and to evaluate to which extent guidelines are used. Methods A cross-sectional survey in the Dutch-speaking part of Belgium is carried out in 39 psychiatric hospitals, 11 psychiatric wards of a general hospital and 61 emergency departments. All physicians are asked for demographic information, their prescribing preferences, their use of guidelines and the type of monitoring (effectiveness, safety). For the basic demographic data and prescription preferences descriptive statistics are given. For comparing prescribing preferences of the drug between groups Chi square tests (or in case of low numbers Fisher’s exact test) were performed. Mc Nemar test for binomial proportions for matched-pair data was performed to see if the prescription preferences of the participants differ between secluded and non-secluded patients. Results 550 psychiatrist and emergency physicians were invited. The overall response rate was 20% (n = 108). The number 1 preferred medication classes were antipsychotics (59.3%) and benzodiazepines (40.7%). In non-secluded patients, olanzapine (22.2%), lorazepam (21.3%) and clotiapine (19.4%) were most frequently picked as number 1 choice drug. In secluded patients, clotiapine (21.3%), olanzapine (21.3%) and droperidol (14.8%) were the three most frequently chosen number 1 preferred drugs. Between-group comparisons show that emergency physicians prefer benzodiazepines significantly more than psychiatrists do. Zuclopenthixol and olanzapine show a particular profile in both groups of physicians. Polypharmacy is more frequently used in secluded patients. Published guidelines and safety or outcome monitoring are rarely used. Conclusions Our results show that prescription practice in Flanders (Belgium) in acute agitation shows a complex relationship with published guidelines. Prescription preferences differ accordingly to medical specialty. These findings should be taken into account in future research.
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Chan EW, Knott JC, Liew D, Taylor DM, Kong DCM. Cost-Minimisation Analysis of Midazolam versus Droperidol for Acute Agitation in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2012.tb00123.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Esther W Chan
- Centre for Medicine Use and Safety, Department of Pharmacology and Pharmacy; Monash University, University of Hong Kong
| | | | - Danny Liew
- Centre for Clinical Epidemiology, Biostatistics and Health Services Research; The University of Melbourne, The Royal Melbourne Hospital
| | | | - David CM Kong
- Centre for Medicine Use and Safety; Monash University; Parkville Victoria
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Chan EW, Knott JC, Taylor DM, Kong DCM. Intravenous Olanzapine for Acute Agitation in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00681.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Esther W Chan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University, and Department of Emergency Medicine, Austin Health
| | | | | | - David CM Kong
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria
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Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DC. In reply. Ann Emerg Med 2013; 61:598-9. [DOI: 10.1016/j.annemergmed.2012.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 11/07/2012] [Accepted: 11/08/2012] [Indexed: 11/28/2022]
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Pacciardi B, Mauri M, Cargioli C, Belli S, Cotugno B, Di Paolo L, Pini S. Issues in the management of acute agitation: how much current guidelines consider safety? Front Psychiatry 2013; 4:26. [PMID: 23675355 PMCID: PMC3646256 DOI: 10.3389/fpsyt.2013.00026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 04/09/2013] [Indexed: 11/29/2022] Open
Abstract
Agitated behavior constitutes up to 10% of emergency psychiatric interventions. Pharmacological tranquilization is often used as a valid treatment for agitation but a strong evidence base does not underpin it. Available literature shows different recommendations, supported by research data, theoretical considerations, or clinical experience. Rapid tranquilization (RT) is mainly based on parenteral drug treatment and the few existing guidelines on this topic, when suggesting the use of first generation antipsychotics and benzodiazepines, include drugs with questionable tolerability profile such as chlorpromazine, haloperidol, midazolam, and lorazepam. In order to systematically evaluate safety concerns related to the adoption of such guidelines, we reviewed them independently from principal diagnosis while examining tolerability data for suggested treatments. There is a growing evidence about safety profile of second generation antipsychotics for RT but further controlled studies providing definitive data in this area are urgently needed.
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Affiliation(s)
- Bruno Pacciardi
- Psychiatry Division, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa Pisa, Italy
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Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DC. Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Ann Emerg Med 2013; 61:72-81. [DOI: 10.1016/j.annemergmed.2012.07.118] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/19/2012] [Accepted: 07/24/2012] [Indexed: 11/15/2022]
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Chan EW, Taylor DM, Knott JC, Liew D, Kong DCM. The pharmacoeconomics of managing acute agitation in the emergency department: what do we know and how do we approach it? Expert Rev Pharmacoecon Outcomes Res 2012. [PMID: 23186399 DOI: 10.1586/erp.12.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The emergency department (ED) is commonly the first point of care for patients with acute behavioral issues from the community. Routinely, clinical management involves the use of benzodiazepine and/or antipsychotic drugs, when initial de-escalation strategies fail. There is currently scant literature available to inform the clinical management and resource utilization of acute agitation in the ED. This article discusses the approach to pharmacoeconomic studies of acute agitation management in the ED. It explores the conduct of such evaluations and highlights the cost and data sources required. The current difficulties experienced in conducting such evaluations are also discussed. Pharmacoeconomic studies related to the management of acute agitation in ED can be challenging. Robust clinical trials incorporating prospectively designed pharmacoeconomic studies will invariably contribute toward a better understanding of this therapeutic area and optimize the use of scarce resources.
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Affiliation(s)
- Esther W Chan
- 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
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