1
|
Ali AA. Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department. J Emerg Med 2024; 67:e42-e49. [PMID: 38816261 DOI: 10.1016/j.jemermed.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.
Collapse
Affiliation(s)
- Afrah A Ali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
| |
Collapse
|
2
|
Grundy AC, Papastravrou Brooks C, Johnston I, Cree L, Callaghan P, Price O. Evaluation of a novel co-designed and co-delivered training package to de-escalate violence and aggression in UK acute inpatient, PICU and forensic mental health settings. J Psychiatr Ment Health Nurs 2024. [PMID: 38922757 DOI: 10.1111/jpm.13074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/15/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Clinical guidelines and staff training recommend using de-escalation over restrictive practices, such as restraint and seclusion Evidence suggests that restrictive practices continue to be used frequently despite training This suggests a lack of impact of existing staff de-escalation training. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: The features of de-escalation training that are acceptable to staff and perceived to be impactful A co-designed and co-delivered training session on a trauma-informed approach to de-escalation on mental health wards was acceptable and perceived to be impactful Those attending training particularly valued how lived experience was incorporated into the training content and co-delivery The organizational and team context may need more consideration in adapting the training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: De-escalation training that adopts a trauma-informed approach and considers the context of ward environments is acceptable to staff Co-delivery models of training to tackle restrictive practice can be acceptable and impactful Further research will show how clinically effective this training is in improving outcomes for service users in ward contexts. ABSTRACT BACKGROUND: Evidence suggests a discrepancy between recommended and routine practice in de-escalation in mental health settings, suggesting a lack of impact of existing training. AIM To investigate the acceptability and perceived impact of a co-designed/delivered training intervention on a trauma-informed approach to de-escalation on mental health wards. METHODS Trainees were invited to complete the Training Acceptability Rating Scale (TARS) post-training. Responses to the quantitative items were summarized using descriptive statistics, and open-text responses were coded using content analysis. RESULTS Of 214 trainees, 211 completed the TARS. The trainees rated the training favourably (median overall TARS = 55/63), as acceptable (median 33/36) and impactful (median 23/27). There were five qualitative themes: modules of interest; multiple perspectives; modes of delivery; moulding to context; and modifying other elements. DISCUSSION The EDITION training was found to be acceptable and impactful, with trainees particularly valuing the co-delivery model. Trainees suggested several ways in which the training could be improved, particularly around the need for further moulding of the intervention to the specific ward contexts/teams. IMPLICATIONS FOR PRACTICE We recommend co-designing and co-delivering staff training to mental health professionals that tackles restrictive practices. RELEVANCE STATEMENT This research is relevant to lived experience practitioners who want to be involved in training mental health professionals around restrictive practices, demonstrating the value and importance of their voice. It is relevant to current providers of de-escalation training, and to staff receiving training, outlining a novel, but acceptable and impactful, form of training on a key area of mental health practice. It is relevant to anyone with an interest in reducing restrictive practice via co-delivered training.
Collapse
Affiliation(s)
- Andrew C Grundy
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | | | - Isobel Johnston
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Lindsey Cree
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Patrick Callaghan
- School of Applied Sciences, London South Bank University, London, UK
| | - Owen Price
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
3
|
Foster AA, Saidinejad M, Li J. Approach to acute agitation in the pediatric emergency department. Curr Opin Pediatr 2024; 36:245-250. [PMID: 38299972 DOI: 10.1097/mop.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED. RECENT FINDINGS Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time. SUMMARY Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.
Collapse
Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor UCLA, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Castro M, Butler M, Thompson AN, Gee S, Posporelis S. Effectiveness and Safety of Intravenous Medications for the Management of Acute Disturbance (Agitation and Other Escalating Behaviors): A Systematic Review of Prospective Interventional Studies. J Acad Consult Liaison Psychiatry 2024; 65:271-286. [PMID: 38309683 DOI: 10.1016/j.jaclp.2024.01.004] [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: 08/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.
Collapse
Affiliation(s)
- Megan Castro
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom
| | - Matt Butler
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom.
| | | | - Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, KCL, London, United Kingdom
| | - Sotiris Posporelis
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
5
|
Wong B, Ismail Z, Watt J, Holroyd-Leduc J, Goodarzi Z. Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care. BMC Geriatr 2024; 24:330. [PMID: 38600482 PMCID: PMC11008022 DOI: 10.1186/s12877-024-04919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/25/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups. METHODS This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis. RESULTS Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions. CONCLUSIONS This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.
Collapse
Affiliation(s)
- Britney Wong
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Jennifer Watt
- Division of Geriatric Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Zahra Goodarzi
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
- Department of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
6
|
Kynoch K, Liu XL, Cabilan CJ, Ramis MA. Educational programs and interventions for health care staff to prevent and manage aggressive behaviors in acute hospitals: a systematic review. JBI Evid Synth 2024; 22:560-606. [PMID: 37851359 DOI: 10.11124/jbies-22-00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE The objective of this review was to determine the effect of educational programs that have been implemented in acute health care settings to manage or prevent aggressive behaviors toward staff perpetrated by patients, families, or visitors. INTRODUCTION Health care staff working within acute-level and tertiary-level hospitals are at high risk of exposure to aggressive behaviors by patients, their family, or visitors. Negative staff and organizational impacts reported in the literature include individual psychological or emotional distress and severe harm, increased absenteeism, high staff turnover, and awarded compensation. Reports of this kind of occupational violence are increasing globally; therefore, strategies to address prevention and management are needed to mitigate the risk of harm to staff and the wider hospital service. Various educational activities have been implemented to address the issue, but the overall effect of these is unclear. INCLUSION CRITERIA Experimental and quasi-experimental studies were considered for inclusion if they reported on an educational program or intervention for staff working within an acute hospital setting and aimed at managing or preventing occupational violence perpetrated by patients, family, or visitors. Reports of programs implemented to address occupational violence, whether verbal or physical, were included. Studies were excluded if they reported on upward violence or bullying, patients in psychiatric or dementia facilities, or pediatric patients, due to the specific care needs of these cohorts. METHODS The following databases were searched: PubMed (PubMed Central), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), Embase, ERIC (ProQuest), Cochrane Central Register of Controlled Trials (Cochrane Library), and Scopus. ProQuest Dissertations and Theses was searched for unpublished studies. To obtain a wider perspective of the issue, studies published in Chinese were also searched in WanFang Database, China National Knowledge Infrastructure, and Chongqing VIP. A date filter of 2008-2023 was applied in a deliberate effort to expand from previous work. No language filters were applied. The review was conducted in accordance with JBI methodology for systematic reviews of effectiveness, and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS The search process retrieved 4681 citations. A total of 32 studies representing 3246 health staff were included in the review. The studies were either before-and-after or pre-test/post-test study designs. Methodological quality of studies varied, with the main issues being absence of CIs within statistical analysis, limited detail on participant selection or attrition/non-response, and underreporting of confounding factors. Educational programs varied in content and duration. Content delivery across the studies also varied, with several didactic, role-play, debriefing, group work, and simulation exercises reported. While studies reported some improvement in self-reported confidence levels, results were mixed for other outcomes. Determining overall effect of included studies was challenging due to heterogeneity within and across studies with regard to intervention types, populations, measurement tools, and outcomes. CONCLUSIONS This review is unable to determine which workplace educational programs had an effect on staff outcomes or on the number of occupational violence incidents. In the future, educators and researchers could use the findings of this review to guide the design of educational programs and employ measures that are comparable to their settings. REVIEW REGISTRATION PROSPERO CRD42020190538. SUPPLEMENTAL DIGITAL CONTENT A Chinese-language version of the abstract of this review is available [ http://links.lww.com/SRX/A33 ].
Collapse
Affiliation(s)
- Kathryn Kynoch
- Mater Health, Brisbane, QLD, Australia
- Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), School of Nursing, Brisbane, QLD, Australia
| | - Xian-Liang Liu
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong, China
- Charles Darwin Centre for Evidence-Based Practice: A JBI Affiliated Group, Brisbane, QLD, Australia
| | - C J Cabilan
- Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Brisbane, QLD, Australia
- Princess Alexandra Hospital Emergency Department, Brisbane, QLD, Australia
- School of Nursing, Midwifery and Social Work, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Mary-Anne Ramis
- Mater Health, Brisbane, QLD, Australia
- Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Brisbane, QLD, Australia
| |
Collapse
|
7
|
Bernstein AM, Clark SB, Pattishall AE, Morris CR, McCarter A, Muething CS, Pavlov AC, Chun T, Call NA. The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings. J Am Psychiatr Nurses Assoc 2024; 30:424-433. [PMID: 35535388 DOI: 10.1177/10783903221093578] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises. AIMS We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs. METHOD Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees. RESULTS Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time. CONCLUSION The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.
Collapse
Affiliation(s)
- Alec M Bernstein
- Alec M. Bernstein, PhD, BCBA-D, Emory University School of Medicine, Atlanta, GA, USA; Marcus Autism Center, Atlanta, GA, USA
| | - Seth B Clark
- Seth B. Clark, MA, BCBA, Children's Healthcare of Atlanta, Atlanta, GA, USA; Marcus Autism Center, Atlanta, GA, USA
| | - Amy E Pattishall
- Amy E. Pattishall, MD, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Claudia R Morris
- Claudia R. Morris, MD, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrea McCarter
- Andrea McCarter, PhD, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Colin S Muething
- Colin S. Muething, PhD, BCBA-D, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA; Marcus Autism Center, Atlanta, GA, USA
| | - Alexis C Pavlov
- Alexis C. Pavlov, PhD, BCBA-D, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA; Marcus Autism Center, Atlanta, GA, USA
| | - Thomas Chun
- Thomas Chun, MPH, MD, Brown University, Providence, RI, USA
| | - Nathan A Call
- Nathan A. Call, PhD, BCBA-D, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA; Marcus Autism Center, Atlanta, GA, USA
| |
Collapse
|
8
|
Hsi L, Ruiz S. Evaluation of Anti-Agitation Medication Prescribing Patterns by Age in the Emergency Department. Fed Pract 2024; 41:S16-S21. [PMID: 38813266 PMCID: PMC11132097 DOI: 10.12788/fp.0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Background Acute agitation frequently occurs in the emergency department. Appropriate management is critical for the safety of all parties involved. Benzodiazepines and antipsychotics are commonly used for agitation, but safety concerns exist with these medications in older adults, even with acute use. The purpose of this study was to compare prescribing practices of anti-agitation medications between adults aged 18 to 64 years and those aged ≥ 65 years. Methods This study was a retrospective chart review of patients who presented to the Veteran Affairs Southern Nevada Healthcare System emergency department and received haloperidol, droperidol, lorazepam, olanzapine, or ziprasidone from August 1, 2019, to July 31, 2022. Veterans were excluded if they had alcohol intoxication, alcohol withdrawal, benzodiazepine withdrawal, or medication administration unrelated to agitation. Safety outcomes included oxygen saturation < 95%, supplemental oxygen use, intubation, QTc prolongation, and new hypotension within 1 hour of medication administration. Results For the 232 patients who met inclusion criteria, baseline characteristics differed significantly. When comparing patients aged 18 to 64 years and those aged ≥ 65 years, the younger cohort had higher rates of substance use disorder diagnosis (55.3% vs 27.5%, P < .001), positive urine drug screen (69.7% vs 22.5%, P < .001), and 72-hour legal hold (59.9% vs 32.5%, P < .001), and lower rates of cognitive impairment or dementia (0.7% vs 48.8%, P < .001), and altered mental status-related diagnosis (2.0% vs 18.8%, P < .001). Anti-agitation medication selection significantly differed based on age (P = .02). Other than lorazepam (P = .007), no significant differences were noted in the dose ordered. No significant differences were observed for safety outcomes or additional anti-agitation doses. Conclusions Anti-agitation prescribing practices may differ between adults aged 18 to 64 years and those aged ≥ 65 years. The findings of this study also suggest that the most common agitation etiologies may differ based on patient age. Additional higher-quality studies are needed to further explore acute agitation in older adults.
Collapse
Affiliation(s)
- Lisa Hsi
- Veterans Affairs Southern Nevada Healthcare System, North Las Vegas
| | - Shannon Ruiz
- Veterans Affairs Southern Nevada Healthcare System, North Las Vegas
| |
Collapse
|
9
|
Wong AH, Nath B, Shah D, Kumar A, Brinker M, Faustino IV, Boyce M, Dziura JD, Heckmann R, Yonkers KA, Bernstein SL, Adapa K, Taylor RA, Ovchinnikova P, McCall T, Melnick ER. Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol. BMJ Open 2024; 14:e082834. [PMID: 38373857 PMCID: PMC10882402 DOI: 10.1136/bmjopen-2023-082834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER NCT04959279; Pre-results.
Collapse
Affiliation(s)
- Ambrose H Wong
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anusha Kumar
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Isaac V Faustino
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Boyce
- Yale New Haven Health System, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rebekah Heckmann
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts System, Worchester, Massachusetts, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karthik Adapa
- Carolina Health Informatics Program, University of North Carolina System, Chapel Hill, North Carolina, USA
| | - Richard Andrew Taylor
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Polina Ovchinnikova
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terika McCall
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
10
|
Wolfe C, McCoin N. Management of the Agitated Patient. Emerg Med Clin North Am 2024; 42:13-29. [PMID: 37977745 DOI: 10.1016/j.emc.2023.06.010] [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: 11/19/2023]
Abstract
The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.
Collapse
Affiliation(s)
- Carmen Wolfe
- Department of Emergency Medicine, Tristar Skyline Medical Center, 3443 Dickerson Pike, Suite 230, Nashville, TN 37207, USA.
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| |
Collapse
|
11
|
Grover P, Kumar M. Pediatric Psychiatric Emergencies. Emerg Med Clin North Am 2024; 42:151-162. [PMID: 37977747 DOI: 10.1016/j.emc.2023.06.017] [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: 11/19/2023]
Abstract
Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.
Collapse
Affiliation(s)
- Purva Grover
- Cleveland Clinic, 6780 Mayfield Road, Mayfield Heights, OH 44124, USA.
| | - Manya Kumar
- Vardhman Mahavir Medical College, Safdarjung Hospital, Ansari Nagar East, New Delhi, Delhi 110029, India
| |
Collapse
|
12
|
Robinson AE, Driver BE, Cole JB, Miner JR, Dreyfuss AP, Strom AW, Brodt ER, Wyatt TE. Factors Associated With Physical Restraint in an Urban Emergency Department. Ann Emerg Med 2024; 83:91-99. [PMID: 37725022 DOI: 10.1016/j.annemergmed.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE To determine what patient characteristics were associated with the application of physical restraints in our emergency department (ED). METHODS This was a retrospective analysis of encounters in the ED of an urban, Level I academic trauma center. We included ED encounters of adult patients (aged ≥18 years) during a 5-year period starting in 2017. We evaluated the independent association of restraint application during an encounter using a generalized estimating equation model. RESULTS There were 464,031 ED encounters during the time period from 162,244 unique patients, including 34,798 (7.5%) with restraint application, comprising 18,166 unique patients. Several variables were associated with an increased likelihood of restraint use during an encounter. The variable with the highest odds ratio was intoxication with drugs or alcohol (adjusted odds ratio [aOR] 8.29; 95% confidence interval (CI) 7.94 to 8.65). American Indian race was associated with increased odds of restraint application (aOR 1.42; 95% CI 1.31 to 1.54) compared to the reference value of White race. Black race (aOR 0.58; 95% CI 0.55 to 0.61) and Hispanic ethnicity (aOR 0.42; 95% CI 0.37 to 0.48) were associated with lower odds of restraint application. CONCLUSIONS Drug and alcohol intoxication were most closely associated with restraint. Encounters in which the patient was American Indian had higher odds of restraint, but this study does not replicate prior findings regarding other racial disparities in restraint.
Collapse
Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Menominee Indian Tribe of Wisconsin, Keshena, WI, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Andrea P Dreyfuss
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Aida W Strom
- Department of Health Equity, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Erik R Brodt
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Thomas E Wyatt
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA; Loyal Shawnee Tribe and Quapaw Nation, OK, USA
| |
Collapse
|
13
|
Dawson D, Bell SB, Hollman N, Lemens T, Obiozor C, Safo D, Manning T. Assaults and Microaggressions Against Psychiatric Residents: Findings from a US Survey. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024:10.1007/s40596-024-01933-7. [PMID: 38291313 DOI: 10.1007/s40596-024-01933-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Psychiatric physicians may experience higher rates of assault than those in other fields. For many reasons, residents may be especially vulnerable. This study updates rates of assaults among US psychiatry residents as well as the reporting rates and emotional effects of these incidents. Little data exists to examine rates of microaggressions against psychiatry residents. METHODS A cross-sectional online survey was distributed through a national residency database via a snowball-sampling approach between June and September of 2021. The questionnaire asked about experiences of verbal, physical, and sexual assaults, as well as microaggressions and their impact. Descriptive analyses of the obtained data were conducted. RESULTS The survey was completed by 275 psychiatry residents from 29 states (63.6% women). At least one form of assault was experienced by 78.9% of participants with 74.5% experiencing verbal, 22.2% experiencing physical, and 6.2% experiencing sexual assault. At least one type of microaggression was experienced by 86.9% of trainees. Elevations in PTSD scores were seen in residents who identified as women and non-White and those physically injured or sexually assaulted. While 92.7% of residents stated their program provided training about assault, 25% of residents indicated they had no training on recognizing and responding to microaggressions. CONCLUSIONS Psychiatric residents experience widespread assault and microaggressions in the clinical setting but often do not report them. Due to the ubiquitous nature of these events, programs should provide training about early recognition and de-escalation techniques for agitation, responding effectively to microaggressions, and the importance of reporting events.
Collapse
Affiliation(s)
- Drew Dawson
- Oklahoma City Indian Clinic, Oklahoma City, OK, USA
| | - Sarah Beth Bell
- University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Nicholas Hollman
- University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Tara Lemens
- University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | | | - Danielle Safo
- University of Oklahoma School of Community Medicine, Tulsa, OK, USA
| | - Tessa Manning
- University of Oklahoma School of Community Medicine, Tulsa, OK, USA.
| |
Collapse
|
14
|
Haywood M, Patel L. Physical Restraint Use in the Pediatric Emergency Department. Pediatr Emerg Care 2023; 39:807-810. [PMID: 37773613 DOI: 10.1097/pec.0000000000003045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
ABSTRACT Children and adolescents can present to the emergency department with acute agitation and aggression due to various physical and/or mental health conditions. With acute agitation/aggression, these patients may present a risk of injury to themselves, their caregivers, or emergency department providers/staff. It is imperative for providers to understand how to safely care for these children. When initial deescalating interventions fail or an underlying etiology for the behavior change cannot be found, the use of physical restraints may be required. Without proper training or preparation, physical restraints can lead to significant morbidity and mortality. Given these potential risks, strict guidelines have been set out by the Center for Medicare and Medicaid Services and the Joint Commission regarding the use of physical restraints in the pediatric population. This article will review approaches to the acutely agitated/aggressive patient, the appropriate use of physical restraints, and recommended assessment/documentation of restraints in the acutely agitated/aggressive pediatric patient.
Collapse
Affiliation(s)
- Mary Haywood
- From the Fellow, Department of Pediatrics, Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | | |
Collapse
|
15
|
Au RT, Hotham E, Suppiah V. Guidelines and treatment for illicit drug related presentations in emergency departments: A scoping review. Australas Psychiatry 2023; 31:625-634. [PMID: 37548216 PMCID: PMC10566224 DOI: 10.1177/10398562231191671] [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] [Indexed: 08/08/2023]
Abstract
OBJECTIVE This review aimed to identify current pharmacological and non-pharmacological treatment employed in emergency departments (EDs) for the management of patients presenting with illicit drug-related presentations (IDP) and compare current treatments with recommendations provided in guidelines. METHOD The review consists of English peer-reviewed journal articles and grey literature published in electronic databases: Ovid MEDLINE, PubMed, Embase Classic+Embase, Ovid Emcare and APA PsycInfo between 2015 and 2022. RESULTS Twelve studies were identified from the search, with agitation and aggression being the most common presentations, and cannabis being the most prevalent illicit drug. Ventilatory support and restraints were the most reported non-pharmacological interventions while benzodiazepines and antipsychotics were the most commonly prescribed pharmacological agents. Non-coercive de-escalation strategies were recommended in all guidelines, with verbal de-escalation being the initial approach before other interventions, such as medications and restraints. However, de-escalation strategies were not reported in any studies. CONCLUSIONS Pharmacological interventions for patients with IDP and related symptoms were in accordance with guidelines. Use of restraints was identified in included studies with notable lack of reporting of de-escalation strategies which may have been deemed insignificant and not reported. Future research could investigate the appropriateness of restrictive interventions as well as the employment of non-restrictive de-escalation strategies.
Collapse
Affiliation(s)
- Ruby Tszwai Au
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Elizabeth Hotham
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Vijayaprakash Suppiah
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Australian Centre for Precision Health, University of South Australia, Adelaide, SA, Australia
| |
Collapse
|
16
|
Aragonés-Calleja M, Sánchez-Martínez V. Experience of coercion among nursing professionals in a medium-stay mental health unit: A qualitative study in Spain. J Psychiatr Ment Health Nurs 2023; 30:983-993. [PMID: 36971519 DOI: 10.1111/jpm.12921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 02/07/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Coercive measures represent an ethical conflict because they limit the person's freedom, compromising their personal autonomy, self-determination and fundamental rights. The reduction of the use of coercive measures implies not only regulations and mental health systems, but also cultural aspects, such as societal beliefs, attitudes, and values. There is evidence about the professionals' views on coercion in acute mental health care units and community settings, but they remain unexplored in inpatient rehabilitation units. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The knowledge about coercion varied from not knowing at all the meaning of the word, to a proper description of the phenomenon. Coercive measures are considered a necessary evil or normalized in mental health care and considered implicit to daily practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The perceptions and attitudes towards coercion might be influenced by the knowledge about the phenomenon. Training of mental health nursing staff in non-coercive practice could help professionals to detect, be conscious towards, and question coercive measures, thus orienting them to the effective implementation of interventions or programmes with evidenced effectiveness to reduce them. ABSTRACT INTRODUCTION: Creating a therapeutic and safe milieu with the minimum coercive measures requires knowing professionals' perceptions and attitudes towards coercion, but they remain unexplored in medium and long-stay inpatient psychiatric rehabilitation units. AIM To explore the knowledge, perception and experience of coercion among nursing staff at a rehabilitation medium-stay mental health unit (MSMHU) in Eastern Spain. METHOD Qualitative phenomenological study including 28 face-to-face, semi-structured interviews based on a script. Data were analysed using content analysis. RESULTS Two main themes were found: (1) therapeutic relationship and treatment in the MSMHU, which included three subthemes: qualities of the professionals for building the therapeutic relationship; perceptions about the persons admitted to the MSMHU; views of the therapeutic relationship and treatment in the MSMHU; (2) Coercion at the MSMHU, comprising five subthemes: professional knowledge; general aspects; emotional impact of coercion; opinions; alternatives. DISCUSSION Coercive measures are often normalized in mental health care and considered implicit to daily practice. A proportion of participants who did not know what coercion is. IMPLICATIONS FOR PRACTICE Knowledge about coercion might influence attitudes towards coercion. Mental health nursing staff could benefit from formal training in non-coercive practice, facilitating the operative implementation of effective interventions or programmes.
Collapse
Affiliation(s)
| | - Vanessa Sánchez-Martínez
- Department of Nursing, Faculty of Nursing and Chiropody, University of Valencia, Valencia, Spain
| |
Collapse
|
17
|
Faden J, Goldberg JF, Citrome L. Improving the pharmacotherapeutic treatment of agitation associated with bipolar disorder. Expert Opin Pharmacother 2023; 24:1811-1822. [PMID: 37581475 DOI: 10.1080/14656566.2023.2248893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Agitation is commonly encountered in people with bipolar disorder, particularly when experiencing a manic episode. The number of approved pharmacological agents to manage acute episodes of agitation in this population is limited. AREAS COVERED A search was conducted using the US National Library of Medicine PubMed.gov resource for English-language papers of clinical trials and reviews/meta-analyses, using the text words 'bipolar disorder' AND 'agitation,' as well as any papers with both two text words in the title, without any date restrictions. EXPERT OPINION Existing pharmacologic options approved by regulatory authorities for the treatment of acute episodes of agitation associated with bipolar disorder have similar degrees of efficacy but differ in their tolerability profiles and ease of use, giving clinicians an opportunity to individualize treatment. The goal is to treat mild-moderate agitation before it evolves into severe agitation, encouraging noninvasive pharmacologic treatment options. Inhaled loxapine and sublingual dexmedetomidine are newer options with rapid onset of action and may be preferable for patients willing to cooperate with treatment.
Collapse
Affiliation(s)
- Justin Faden
- Department of Psychiatry and Behavioral Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, New York, Valhalla, USA
| |
Collapse
|
18
|
Saidinejad M, Duffy S, Wallin D, Hoffmann JA, Joseph MM, Schieferle Uhlenbrock J, Brown K, Waseem M, Snow S, Andrew M, Kuo AA, Sulton C, Chun T, Lee LK. The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Pediatrics 2023; 152:e2023063256. [PMID: 37584106 DOI: 10.1542/peds.2023-063256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/17/2023] Open
Abstract
Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.
Collapse
Affiliation(s)
- Mohsen Saidinejad
- Department of Clinical Emergency Medicine & Pediatrics, David Geffen School of Medicine at UCLA, Institute for Health Services and Outcomes Research, The Lundquist Institute for Biomedical Innovation at Harbor UCLA, and Department of Emergency Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Susan Duffy
- Department of Emergency Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Dina Wallin
- Department of Emergency Medicine, University of California San Francisco, UCSF Benioff Children's Hospital, San Francisco, California
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Evanston, Illinois
| | - Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, University of Florida Health Sciences Center, Jacksonville, Jacksonville, Florida
| | | | - Kathleen Brown
- Emergency Medicine and Trauma Center, Children's National Hospital, Washington, District of Columbia
| | - Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Sally Snow
- Independent Consultant, Pediatric Emergency and Trauma Nursing
| | | | - Alice A Kuo
- Departments of Medicine and Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Carmen Sulton
- Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, CPG Sedation Services, Children's Healthcare of Atlanta, Egleston, Atlanta, Georgia
| | - Thomas Chun
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Hasbro Children's Hospital, Warren Alpert Medical School of Medicine at Brown University, Providence, Rhode Island
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Kang C, Williams A, Butala N. Prescribing Practices for Agitation Medication in Obese Patients Admitted to the Emergency Department. J Psychiatr Pract 2023; 29:359-366. [PMID: 37678365 DOI: 10.1097/pra.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Weight is a factor that influences the dosages of many medications, although no clinical studies have evaluated this factor in the use of agitation medications in the obese population. The objectives of this study were to assess the need for weight considerations in dosing antipsychotics and benzodiazepines for patients with agitation and to assess prescribing patterns in agitated patients. METHODS This retrospective cohort study compared outcomes between obese and nonobese adult patients who received at least one parenteral administration of an antipsychotic or benzodiazepine for agitation in the emergency department. The primary outcomes were total antipsychotic and benzodiazepine doses within 24 hours (in chlorpromazine equivalents and lorazepam equivalents, respectively). Key secondary outcomes included antipsychotic and benzodiazepine doses used for first administration, incidence of repeat emergency medication administration within 24 hours, time to next administration, and number of repeat administrations within 24 hours. RESULTS The study examined 115 patient encounters in each cohort of patients in the study. The baseline characteristics of the 2 study cohorts were similar. Both groups had similar mean 24-hour antipsychotic usage [272.7 chlorpromazine equivalents (nonobese cohort), 313.5 chlorpromazine equivalents (obese cohort); P=0.157] and mean 24-hour benzodiazepine usage [0.9 lorazepam equivalents (both cohorts); P=0.750]. Differences between the study cohorts on all of the secondary outcomes were also not statistically significant (P>0.05). DISCUSSION This study did not find the use of higher dosages of agitation medication in the obese compared with the nonobese population. Future prospective trials, with possible emphasis on individual medications, specific etiologies of agitation, or morbid obesity, are required to confirm this finding or to elucidate potential differences in optimal medication dosages for the obese population.
Collapse
|
20
|
Lowrie LN, Duncan L, Samuels DA, Ablah E, Ofei-Dodoo S. Prehospital Clinical Decision-Making for Medication Administration for Behavioral Emergencies. Kans J Med 2023; 16:189-193. [PMID: 37791024 PMCID: PMC10544877 DOI: 10.17161/kjm.vol16.20261] [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] [Received: 04/27/2023] [Accepted: 06/21/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Prehospital behavioral emergency protocols provide guidance on when a medication may be necessary for prehospital behavioral emergency. However, the final decision of which medication to administer to a patient is made independently by paramedics. The authors evaluated circumstances in a prehospital behavioral emergency when paramedics considered chemical restraints, and factors that go into choosing which medications to administer. Methods A qualitative research design was used involving paramedics from a Midwestern County in the United States, between November 18 and 26, 2019. A total of 149 paramedics were asked to complete a survey consisting of two open-ended questions to measure their clinical decision-making process and factors considered when selecting a medication from a behavioral emergencies protocol. An immersion-crystallization approach was used to analyze the content of the interviews. Results There was a 53% (n = 79) response rate. Six major themes emerged regarding the paramedics' decisions to use medication for behavioral emergencies: safety of the patients and paramedics, inability to use calming techniques, severity of the behavioral emergency, inability to assess the patient due to presentation, etiology of the behavioral episode, and other factors, such as age, size, and weight of the patient. Six major themes emerged regarding factors considered when choosing medication for behavioral emergency: etiology of the behavioral emergency, patient presentation, the patients' history and age, desired effect and intended outcome of the medication, and other factors. Conclusions Emergency medical services (EMS) paramedics relied on several factors, such as safety of all parties involved and etiology of the behavioral emergency in deciding when, and which medication to use in a behavioral emergency. The findings could help EMS administrators to develop protocols, such as how paramedics respond and treat patients with behavioral health emergencies.
Collapse
Affiliation(s)
| | - Leah Duncan
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Department of Family and Community Medicine
| | | | - Elizabeth Ablah
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Department of Population Health, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Samuel Ofei-Dodoo
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Department of Family and Community Medicine
| |
Collapse
|
21
|
Jones N, Decker VB, Houston A. De-Escalation Training for Managing Patient Aggression in High-Incidence Care Areas. J Psychosoc Nurs Ment Health Serv 2023; 61:17-24. [PMID: 36853038 DOI: 10.3928/02793695-20230221-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Health care personnel who have close, face-to-face patient contact experience more workplace violence (WPV) than employees in other fields. Certain health care departments (i.e., high-incidence care areas) have elevated rates of WPV that can have adverse emotional, physical, and financial consequences for patients, employees, and institutions. Health care workers need de-escalation training to efficiently manage patient aggression while also safeguarding patients' dignity and patient-provider trust. The current Plan, Do, Study, Act quality improvement project used insights from an in-depth literature review to create a 1-hour, evidence-based, in-service de-escalation training for personnel from high-incidence care areas. A pre/post design was used to evaluate participants' responses to the Confidence Coping with Patient Aggression Instrument. Post-training, participants reported significantly increased feelings of safety regarding potential patient aggression (p = 0.001) and more efficacy regarding their aggression management techniques (p = 0.039). Based on the training's results, recommendations were made for future institutional de-escalation initiatives. [Journal of Psychosocial Nursing and Mental Health Services, 61(8), 17-24.].
Collapse
|
22
|
Abstract
ABSTRACT The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.
Collapse
Affiliation(s)
| | - Carl R Baum
- Professor, Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
23
|
Seggie AJR. Using Verbal De-escalation to Manage Children With Autism in the Emergency Department. Pediatr Emerg Care 2023; 39:553. [PMID: 37276069 DOI: 10.1097/pec.0000000000002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
|
24
|
Affiliation(s)
- Isaac Kah Siang Ng
- NUHS Internal Medicine Residency Programme, Department of Medicine, National University Hospital, Singapore
| | - Joo Wei Chua
- Fast and Chronic Programme, Alexandra Hospital; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
| | - Yit Shiang Lui
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Li Feng Tan
- Healthy Ageing Programme, Alexandra Hospital, Singapore
| | - Desmond Boon Seng Teo
- Fast and Chronic Programme, Alexandra Hospital; Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore
| |
Collapse
|
25
|
Priest KC, Balasanova AA, Levander XA, Chan B, Blazes CK, Mahan J, Brown J, Mahoney S, Peng L, Mahoney S, Lundy T, Englander H. Caring for Hospitalized Adults with Methamphetamine Use Disorder: A Proposed Clinical Roadmap. Am J Med 2023; 136:507-509. [PMID: 36739062 PMCID: PMC10947159 DOI: 10.1016/j.amjmed.2023.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Kelsey C Priest
- School of Medicine, MD/PhD Program, Oregon Health & Science University, Portland, OR; Department of Psychiatry, Stanford University School of Medicine, Stanford, CA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Alëna A Balasanova
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE
| | - Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Brian Chan
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | | | - John Mahan
- Jackson County Health and Human Services, Medford, OR
| | - Jessica Brown
- IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Stacey Mahoney
- IMPACT Team, Oregon Health & Science University, Portland, OR; Harmony Academy Recovery High School, Lake Oswego, OR
| | - Linda Peng
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Sean Mahoney
- IMPACT Team, Oregon Health & Science University, Portland, OR; Mental Health & Addiction Association of Oregon, Portland, OR
| | - Traci Lundy
- IMPACT Team, Oregon Health & Science University, Portland, OR; Mental Health & Addiction Association of Oregon, Portland, OR
| | - Honora Englander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| |
Collapse
|
26
|
Hamrick B, Van Hassel T, Snyder D, Stephens C. Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence. J Emerg Nurs 2023; 49:403-414. [PMID: 36272824 DOI: 10.1016/j.jen.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/10/2022] [Accepted: 09/15/2022] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Patient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings. METHODS This quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression - Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation. RESULTS Violent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation. DISCUSSION Using an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.
Collapse
|
27
|
Gallen K, Sonnenberg J, Loughran C, Smith MJ, Sheppard M, Schuster K, Kaufman E, Song JS, Hall EC. Health Effects of Policing in Hospitals: a Narrative Review. J Racial Ethn Health Disparities 2023; 10:870-882. [PMID: 35267188 DOI: 10.1007/s40615-022-01275-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals. OBSERVATIONS Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being. CONCLUSIONS AND RELEVANCE Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.
Collapse
Affiliation(s)
- Kate Gallen
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Jake Sonnenberg
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | | | | | - Mildred Sheppard
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, DC, 20010, USA
| | - Kirsten Schuster
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Elinore Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ji Seon Song
- School of Law, University of California, Irvine, CA, USA
| | - Erin C Hall
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA.
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, DC, 20010, USA.
| |
Collapse
|
28
|
Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| |
Collapse
|
29
|
Tosswill H, Cabilan CJ, Learmont B, Taurima K. A descriptive study on the use of restrictive interventions for potentially or actually violent patients in the emergency department. Australas Emerg Care 2023; 26:7-12. [PMID: 35882619 DOI: 10.1016/j.auec.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/03/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Restrictive interventions (chemical, physical, or mechanical restraints) to manage patients who are potentially or actually violent in the emergency department (ED) can be harmful and costly. Non-restrictive interventions are advocated; but this must be preceded with an understanding of patient characteristics that influence their use. A study was conducted to describe the use of restrictive interventions and ascribe it with patient characteristics in the ED. METHODS Records from October 2020 to March 2021 in the occupational violence database were used to analyse patient characteristics and restrictive interventions. Logistic regression was used to establish influencing factors of restrictive interventions adjusting for clinically relevant confounders. RESULTS Of the N = 1276 potentially or actually violent patients, 70 % received restrictive interventions. Chemical restraint was common, with 1 in 2 patients receiving either oral medication or intramuscular injection. Probability of restrictive interventions were higher in patients who were intoxicated [(adjusted odds ratio (aOR) 3.48, 95 % confidence interval (CI) 1.675-7.21)], had high triage score (aOR 2.084, 95 % CI 1.094-3.96), and were in the ED involuntarily (aOR 1.494, 95 % CI 1.105-2.020). CONCLUSION The results reveal the need for multifaceted approaches that limit the presentations of, and minimise restrictive interventions among, potentially or actually violent patients.
Collapse
Affiliation(s)
- Hayden Tosswill
- The University of Queensland, Faculty of Medicine, Brisbane, Australia
| | - C J Cabilan
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia.
| | - Ben Learmont
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia
| | - Karen Taurima
- Princess Alexandra Hospital Emergency Department, Brisbane, Australia
| |
Collapse
|
30
|
Dinoso L, Baudoin C. Using Principles of Therapeutic Communication to Enhance Trauma-Informed Care in the Critical Care Setting to Promote Positive Encounters. Crit Care Nurs Clin North Am 2023; 35:235-246. [PMID: 37127379 DOI: 10.1016/j.cnc.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Traumatic events such as hospitalization of family members in the intensive care setting can influence communication interactions between health-care workers and family members not just because of the acute situation but because it brings feelings resulting from past traumatic events to the surface. Providing trauma-informed care to all patients and families in the critical care setting improves communication and results in encounters that are less likely to result in an escalation of negative emotions and outbursts and provides an environment that is conducive to interprofessional communication between families, patients, and health-care workers.
Collapse
Affiliation(s)
- Liv Dinoso
- School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900 Gravier Street, #331, New Orleans, LA 70112, USA.
| | - Colette Baudoin
- School of Nursing, Louisiana State University Health Sciences Center New Orleans, 1900 Gravier Street, #417, New Orleans, LA 70112, USA
| |
Collapse
|
31
|
Galbert I, Azab AN, Kaplan Z, Nusbaum L. Staff attitudes and perceptions towards the use of coercive measures in psychiatric patients. Int J Ment Health Nurs 2023; 32:106-116. [PMID: 36070221 DOI: 10.1111/inm.13064] [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] [Accepted: 08/21/2022] [Indexed: 01/14/2023]
Abstract
The failure of efforts to significantly reduce the use of physical coercive measures (PCMs) in psychiatric hospitals remains a global concern. There is a gap in the understanding of staff's characteristics that may affect their attitudes and perceptions towards PCMs. This study used a cross-sectional design to examine the attitudes and perceptions of staff working at a mental health centre in Israel regarding the use of PCMs and to explore whether staff attitudes differed depending on their professional and demographic background. This study also sought to explore staff willingness to accept a policy of reducing the use of PCMs. The data were collected from 149 staff members (nurses, physicians, and auxiliary staff) working at mental health centre, using a questionnaire developed for this study. The findings indicate a low degree of support for use of PCMs among participants who were older, female, more qualified psychiatric nurses, with longer duration of employment, and those who have not participated in coercive intervention in the past year. The majority of the sample reported a low willingness to reduce the use of PCMs, and a lack of institutional support after participating in a coercive event. High hospital occupancy and insufficient staffing were perceived as contributing factors to coercive incidents. Therefore, availability of trained and experienced staff, elimination of organizational barriers, along with creating and maintaining a safe clinical environment should be a priority. Alternative non-coercive interventions should further be taught and used for managing aggressive and violent behaviour in the psychiatric clinical settings.
Collapse
Affiliation(s)
- Ilya Galbert
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Abed N Azab
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel.,Department of Clinical Biochemistry and Pharmacology, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Zeev Kaplan
- Beer-Sheva Mental Health Center, Beer-Sheva, Israel.,Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| | - Lika Nusbaum
- Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev Faculty of Health Sciences, Beer-Sheva, Israel
| |
Collapse
|
32
|
Faden J, Musselman M, Citrome L. Sublingual dexmedetomidine: repurposing an anesthetic as an anti-agitation agent. Expert Rev Neurother 2023; 23:97-106. [PMID: 36707066 DOI: 10.1080/14737175.2023.2174430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Especially when acutely ill, individuals with schizophrenia and bipolar disorder can present with agitated behavior. The initial approach to agitation management are non-pharmacologic strategies such as verbal de-escalation techniques; however, pharmacologic interventions may be needed. Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist, and a sublingual formulation has been approved in the US for the treatment of agitation associated with schizophrenia and bipolar disorder in adults. AREAS COVERED The authors review the published literature on sublingual dexmedetomidine using the US National Library of Medicine's PubMed.gov resource. Pharmacodynamics, pharmacokinetics, and efficacy and tolerability findings are summarized. The authors also provide a discussion to its potential place in the treatment armamentarium. EXPERT OPINION Sublingual dexmedetomidine is an effective and well-tolerated pharmacologic option for the treatment of agitation associated with schizophrenia and bipolar disorder. The sublingual method of administration allows for a rapid onset of action with treatment effects beginning as early as 20 minutes after administration. Adverse effects include somnolence, hypotension, oral paresthesia, hypoesthesia, and dry mouth. Further study will be needed to evaluate sublingual dexmedetomidine in real-world patients receiving concomitant psychotropic medications.
Collapse
Affiliation(s)
- Justin Faden
- Department of Psychiatry and Behavioral Sciences, Temple University School of Medicine, Philadelphia, PA, United States
| | - Meghan Musselman
- Department of Psychiatry and Behavioral Sciences, Temple University School of Medicine, Philadelphia, PA, United States
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, New York, NY, United States
| |
Collapse
|
33
|
Soenen C, Van Overmeire R, Six S, Bilsen J, De Backer L, Glazemakers I. Aggression in mental health care: Opportunities for the future-A qualitative study on the challenges when defining and managing aggression across inpatient disciplines. J Psychiatr Ment Health Nurs 2023. [PMID: 36708052 DOI: 10.1111/jpm.12904] [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: 03/08/2022] [Revised: 12/31/2022] [Accepted: 01/11/2023] [Indexed: 01/29/2023]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Aggression towards caregivers is a global phenomenon in mental health care. Although attempts have been made to define aggression, there is no globally accepted definition. Discrepancies in defining aggression can lead to differences in judgement and a sub-par management of aggression. The fact that different disciplines work together in mental health care makes it an even more pressing matter as no research was found regarding a multidisciplinary definition of aggression. Currently, coercive measures, such as isolation, sedation or restraints, are the most common ways of managing aggression. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Mental healthcare nurses and psychologists defined aggression by previous experiences, and they also agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Several opportunities and examples of best practice were given by the participants, but the consensus was that caregivers are in need of alternatives when they are face to face with acute aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is vital for residential units to agree on a definition of aggression and acute aggression. It is our belief that this can aid them in preventing and de-escalating aggression as well as diminishing the use of coercive measures. Further primary research exploring the opportunities of non-coercive techniques, a multidisciplinary approach and the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers is also needed. ABSTRACT INTRODUCTION: Aggression by patients against healthcare workers is a global recurring phenomenon in mental health care. Discrepancies in defining aggression can lead to differences in judgement, which in turn causes difficulties in managing aggression. The multidisciplinary nature of mental healthcare makes a standardized definition an even more pressing matter. No studies, however, were found exploring the way different disciplines approach the definition of aggression. Although traditional methods of managing aggression rely on coercive methods, current research favours the use of non-coercive measures. AIM The aim of this study was to explore the different ways mental healthcare nurses and psychologists define and manage aggression in a residential unit. METHOD A qualitative research design was used, consisting of interviews and focus groups. Transcripts were analysed using a reflexive thematic approach. RESULTS Three major themes were found: (1) approaches towards defining aggression, (2) experiencing aggression and (3) managing aggression: the need for alternatives. DISCUSSION In this study, aggression is defined by how aggression has been experienced, both mental health nurses and psychologists agree that there are no alternatives in managing aggression when non-coercive techniques do not work. Aggression is considered an integral part of the job indicating an "aggression-tolerating" workplace. IMPLICATIONS FOR PRACTICE Three implications for practice were identified: (1) It is vital for residential units to agree on a broad-based definition of aggression, (2) further primary research exploring the opportunities of non-coercive techniques and a multidisciplinary approach is crucial and (3) the relationship between a workplace culture normalizing aggression and the mental well-being of healthcare workers also needs further study.
Collapse
Affiliation(s)
- Clemens Soenen
- The Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and Odisee University of Applied Sciences, Antwerp, Belgium
| | - Roel Van Overmeire
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Stefaan Six
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Johan Bilsen
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Lieve De Backer
- The Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| | - Inge Glazemakers
- The Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| |
Collapse
|
34
|
Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:74-79. [PMID: 37205035 PMCID: PMC10172531 DOI: 10.1176/appi.focus.23022001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The treatment of severe mental illness has undergone a paradigm shift over the last fifty years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition. The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency department's (ED's) that are not designed for their needs. Increasingly, many of those individuals end up waiting in ED's for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent in ED's that it has been given a name: "boarding". This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and system-wide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic. Reprinted with permission from American Psychiatric Association. Copyright © 2019.
Collapse
|
35
|
Stubbe DE. Psychiatric Emergencies: Empowering Connections to De-escalate Aggression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:54-57. [PMID: 37205026 PMCID: PMC10172544 DOI: 10.1176/appi.focus.20220079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Dorothy E Stubbe
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
36
|
Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
37
|
Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:35-45. [PMID: 37205032 PMCID: PMC10172538 DOI: 10.1176/appi.focus.20220064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.
Collapse
Affiliation(s)
- Ashley Curry
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Nasuh Malas
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Megan Mroczkowski
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Victor Hong
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Kimberly Nordstrom
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Christina Terrell
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| |
Collapse
|
38
|
Thompson AD, Berkman ER, Simmons SW, Porter KM, Kroon L, Goldman R, Ramasamy RS. Ethical Considerations in Balancing Use of Seclusion and Restraint With Risk of COVID-19 Exposure: Recommendations for Youth Inpatient Psychiatry Units. J Am Acad Child Adolesc Psychiatry 2022; 61:1319-1321. [PMID: 35513190 PMCID: PMC9057649 DOI: 10.1016/j.jaac.2022.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
The onset of the COVID-19 pandemic has presented unique challenges for inpatient psychiatry units (IPUs). IPUs, especially those caring for children and adolescents, rely heavily on milieu group programming to provide care and supervision for patients, and have had to adapt unit policies and procedures to maintain a therapeutic milieu while minimizing COVID-19 transmission.1 Simultaneously providing care while preventing transmission of COVID-19 within IPUs is a formidable task, and many IPUs face the additional challenge of treating youth who have been exposed to, or are actively infected with, COVID-19. In addition, given the need to prevent transmission of COVID-19, recommendations include "mandatory quarantine and isolation when patients refuse to adhere to guidelines,"2 potentially leading to the use of restraint when patients attempt to leave isolation; thus a conflict between the potential risks of enforcing infection prevention policies in order to reduce virus transmission and best practices of eliminating seclusion and restraint (S/R) creates an ethical dilemma for IPUs.
Collapse
Affiliation(s)
- Alysha D. Thompson
- Seattle Children’s Hospital, Washington,University of Washington, Seattle,Correspondence to Alysha D. Thompson, PhD, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105
| | - Emily R. Berkman
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
| | - Shannon W. Simmons
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
| | | | | | | | - Ravi S. Ramasamy
- Seattle Children’s Hospital, Washington,University of Washington, Seattle
| |
Collapse
|
39
|
Lawrence RE, Krumheuer A, Loh R, Stanley B, Simpson SA. Persons Who Engage in Self-Harm While in the Emergency Department: A Case-Control Analysis. J Nerv Ment Dis 2022; 210:736-740. [PMID: 36179373 PMCID: PMC9525888 DOI: 10.1097/nmd.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Some patients engage in self-harm behaviors while in the emergency department. Risk factors for self-harm have been described for inpatient and outpatient/community settings, but not among emergency department patients. Authors conducted case-control, retrospective reviews of medical records and incident reports for emergency department patients in two academic medical centers. Variables were analyzed using conditional logistic regression. There were 113 individuals who engaged in self-harm while in the emergency department and 226 individuals who did not. Four variables were significant in the final model: a history of nonsuicidal self-harm (odds ratio [OR], 4.28; 95% confidence interval [CI], 1.95-9.41), opioid use in the prior 2 weeks (OR, 2.89; CI, 1.19-7.02), current manic episode (OR, 3.59; CI, 1.33-9.70), and a history of seizures (OR, 4.19; CI, 1.16-15.14). Risk of self-harm while in the emergency department may be mitigated with interventions that support adaptive coping skills, promptly address pain and withdrawal symptoms, and treat mania.
Collapse
Affiliation(s)
- Ryan E Lawrence
- Department of Psychiatry, New York State Psychiatric Institute, New York, New York
| | - Aaron Krumheuer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ryan Loh
- Department of Behavioral Health Services, Denver Health and Hospital Authority, Denver, Colorado
| | - Barbara Stanley
- Department of Psychiatry, New York State Psychiatric Institute, New York, New York
| | - Scott A Simpson
- Department of Behavioral Health Services, Denver Health and Hospital Authority, Denver, Colorado
| |
Collapse
|
40
|
Cheung DSK, Wang SS, Li Y, Ho KHM, Kwok RKH, Mo SH, Bressington D. Sensory-based interventions for the immediate de-escalation of agitation in people with dementia: A systematic review. Aging Ment Health 2022:1-12. [PMID: 36073320 DOI: 10.1080/13607863.2022.2116404] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Objectives: Sensory-based interventions are commonly used to reduce the occurrence of agitation in people with dementia over extended periods. However, the evidence regarding their immediate de-escalation effects is unclear. The objectives of this systematic review are to (a) identify which sensory-based interventions have been used for de-escalating agitation and (b) examine the immediate effects of these interventions on de-escalating agitation in people with dementia.Methods: A systematic review was performed in accordance with PRISMA guidelines. Data sources were identified by searching Embase, Medline, PsycINFO, and CINAHL for publications up to 2 March 2022. The de-escalating agitation effect had to be measured during the intervention or within 15 min after commencing the treatment. Only randomized controlled trials or quasi-experimental studies published in English were included.Results: Nine studies met the inclusion criteria: two randomized controlled trials, one cross-over study, and six quasi-experimental studies. All were conducted in Western countries, involving a total of 246 participants. Music-related interventions were investigated in seven studies, and a positive effect on de-escalating agitation was found, with no side-effects. All of the studies had methodological limitations, including a single group design, blinding, an insufficient sample size, and imprecisely reported results.Conclusion: There is a profound dearth of rigorous studies examining the immediate agitation de-escalating effects of sensory-based interventions on people with dementia. However, the limited evidence on music-related interventions is encouraging. More rigorous research is recommended to confirm the effects.
Collapse
Affiliation(s)
| | - Shan Shan Wang
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Yan Li
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Ken Hok Man Ho
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Robin Ka Ho Kwok
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Siu Hong Mo
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Daniel Bressington
- College of Nursing and Midwifery, Charles Darwin University, Casuarina, Northern Territory, Australia
| |
Collapse
|
41
|
Ojeda VD, Berliant E, Parker T, Lyles M, Edwards TM, Jimenez C, Linke S, Hiller-Venegas S, Lister Z. Overview of a Pilot Health-focused Reentry Program for Racial/Ethnic Minority Probationers ages 18 to 26 in Southern California. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2022; 66:1303-1326. [PMID: 33980068 DOI: 10.1177/0306624x211013739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
There is a significant gap in reentry programming that is tailored to the needs of young adults ages 18 to 26 who are in a unique developmental life stage that involves ongoing maturity in their neurobiology, cognitive development, and social and financial transitions to adulthood and independence. This article describes the structure and approach of a 6-month health-focused reentry program designed for racial/ethnic minority young adult (YA) probationers in Southern California. The UCSD RELINK program includes service navigation and an optional psychoeducation health coaching program to build health literacy, problem-solving, and executive functioning skills relevant across multiple life domains. We describe participant characteristics and service needs at intake. Between 2017 and 2019, 122 YA probationers ages 18 to 26 responded to interviewer-administered baseline surveys. Participants needed basic services including housing, nutrition assistance, employment, and educational/vocational training. Depression and anxiety symptoms, Adverse Childhood Events, trauma, and unmet physical and mental health care needs were pervasive. Given the dearth of research on reentry programming for YA, this article documents the approaches taken in this multi-pronged health-focused reentry program to ensure that the program was tailored to YA reentrants' comprehensive needs. These data serve to concretely illustrate the range of needs and how YA reentrants view their own health and social needs in the context of multiple competing demands; such data may be useful for program planners and policymakers seeking to advance service delivery for YA minority reentrants.
Collapse
Affiliation(s)
- Victoria D Ojeda
- University of California, San Diego School of Medicine, La Jolla, USA
| | - Emily Berliant
- University of California, San Diego School of Medicine, La Jolla, USA
| | - Tamara Parker
- University of California, San Diego School of Medicine, La Jolla, USA
| | - Maurice Lyles
- University of California, San Diego School of Medicine, La Jolla, USA
| | - Todd M Edwards
- University of California, San Diego School of Medicine, La Jolla, USA
- University of San Diego, CA, USA
| | - Cielo Jimenez
- University of California, San Diego School of Medicine, La Jolla, USA
| | - Sarah Linke
- University of California, San Diego School of Medicine, La Jolla, USA
| | | | - Zephon Lister
- University of California, San Diego School of Medicine, La Jolla, USA
- Loma Linda University, CA, USA
| |
Collapse
|
42
|
Manning T, Bell SB, Dawson D, Kezbers K, Crockett M, Gleason O. The Utilization of a Rapid Agitation Scale and Treatment Protocol for Patient and Staff Safety in an Inpatient Psychiatric Setting. Psychiatr Q 2022; 93:915-933. [PMID: 36006571 PMCID: PMC9402403 DOI: 10.1007/s11126-022-10001-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 10/27/2022]
Abstract
Agitation is a common and potentially dangerous condition requiring rapid recognition and treatment in acute psychiatric units. Prompt intervention can prevent a patient with agitation from harming themselves, harming others, or needing restraints or seclusion. After the review of numerous guidelines, the Modified Agitation Severity Scale (MASS) agitation treatment protocol was developed to identify and manage agitation in an inpatient adult psychiatric setting. This protocol involved modifying an existing agitation scale and pairing scores with a treatment algorithm to indicate which behavioral and medication interventions would be most appropriate. All scoring and interventions were recorded in the electronic medical record (EMR). Three months of data were collected before and after the protocol was implemented. The new, modified scale had high reliability and correlated well with another validated agitation scale. Perceived patient safety was high during both study phases. Nurses' perceptions of safety trended upward after the protocol was implemented, though these differences were not significant, likely due to insufficient power. Although there was no decrease in seclusion events after implementation of the treatment protocol, there was a 44% decrease in restraint events and average restraint minutes per incident. Despite a potential increase in workload for nursing staff, implementation of the protocol did not increase burnout scores. Physicians continued to order the protocol for 55% of patients after the study period ended. These findings suggest that including a rapid agitation assessment and protocol within the EMR potentially improves nurses' perceptions of unit safety, helps assess treatment response, reduces time patients spend restrained, and supports decision making for nurses.
Collapse
Affiliation(s)
- Tessa Manning
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA.
| | - Sarah Beth Bell
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Drew Dawson
- Oklahoma City Indian Clinic, 5208 W Reno Ave, Oklahoma City, OK, USA
| | - Krista Kezbers
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA.,Health Promotion Research Center, The University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Micheal Crockett
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Ondria Gleason
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| |
Collapse
|
43
|
Lipscombe C, Akhlaghi H, Groombridge C, Bernard S, Smith K, Olaussen A. Intubation Rates following Prehospital Administration of Ketamine for Acute Agitation: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2022; 27:1016-1030. [PMID: 35913093 DOI: 10.1080/10903127.2022.2108178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/27/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Ketamine is a fast-acting, dissociative anesthetic with a favorable adverse effect profile that is effective for managing acute agitation as a chemical restraint in the prehospital and emergency department (ED) settings. However, some previously published individual studies have reported high intubation rates when ketamine was administered prehospitally. OBJECTIVE This systematic review aims to determine the rate and settings in which intubation following prehospital administration of ketamine for agitation is occurring, as well as associated indications and adverse events. METHODS We searched PubMed, Scopus, Ovid MEDLINE, Embase, CINAHL Plus, PsycINFO, the Cochrane Library, ClinicalTrials.gov, OpenGrey, Open Access Theses and Dissertation, and Google Scholar from the earliest possible date until 13/February/2022. Inclusion criteria required studies to describe agitated patients who received ketamine in the prehospital setting as a first-line drug to control acute agitation. Reference lists of appraised studies were screened for additional relevant articles. Study quality was assessed using the Newcastle-Ottawa quality assessment scale. Synthesis of results was completed via meta-analysis, and the GRADE tool was used for certainty assessment. RESULTS The search yielded 1466 unique records and abstracts, of which 50 full texts were reviewed, resulting in 18 being included in the analysis. All studies were observational in nature and 15 were from USA. There were 3476 patients in total, and the overall rate of intubation was 16% (95% confidence interval [CI] = 8%-26%). Most intubations occurred in the ED. Within the studies, the prehospital intubation rate ranged from 0% to 7.9% and the ED intubation rate ranged from 0 to 60%. The overall pooled prehospital intubation rate was 1% (95% CI = 0%-2%). The overall pooled ED intubation rate was 19% (95% CI = 11%-30%). The most common indications for intubation were for airway protection and respiratory depression/failure. CONCLUSIONS There is wide variation in intubation rates between and within studies. The majority of intubations performed following prehospital administration of ketamine for agitation took place in the ED.
Collapse
Affiliation(s)
- Carlos Lipscombe
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Hamed Akhlaghi
- Emergency Department, St Vincent's Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Psychology, Faculty of Health, Deakin University, Geelong, Australia
| | - Christopher Groombridge
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stephen Bernard
- Centre for Research and Evaluation, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Alexander Olaussen
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Victoria, Australia
| |
Collapse
|
44
|
O'Donovan D, Boland C, Carballedo A. Current trends in restrictive interventions in psychiatry: a European perspective. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.
Collapse
|
45
|
Zaki HA, Shaban E, Bashir K, Iftikhar H, Zahran A, Salem EEDM, Elmoheen A. A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review. Cureus 2022; 14:e26162. [PMID: 35891834 PMCID: PMC9302860 DOI: 10.7759/cureus.26162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 01/08/2023] Open
Abstract
We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine. This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions. Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups. We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.
Collapse
|
46
|
Bliton JN, Zakrison TL, Vong G, Johnson DA, Rattan R, Hanos DS, Smith RN. Ethical Care of the Traumatized: Conceptual Introduction to Trauma-Informed Care for Surgeons and Surgical Residents. J Am Coll Surg 2022; 234:1238-1247. [PMID: 35703822 DOI: 10.1097/xcs.0000000000000183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.
Collapse
Affiliation(s)
- John N Bliton
- From the Wellstar Atlanta Medical Center, Atlanta, GA (Bliton)
| | - Tanya L Zakrison
- Trauma and Acute Care Surgery, University of Chicago Medicine, Chicago, IL (Zakrison, Johnson)
| | - Gerard Vong
- Emory University, Center for Ethics, Atlanta, GA (Vong)
| | - Dwane A Johnson
- Trauma and Acute Care Surgery, University of Chicago Medicine, Chicago, IL (Zakrison, Johnson)
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL (Rattan)
| | - Dustin S Hanos
- Emory University School of Medicine, Grady Hospital, Atlanta, GA (Hanos, Smith)
| | - Randi N Smith
- Emory University School of Medicine, Grady Hospital, Atlanta, GA (Hanos, Smith)
| |
Collapse
|
47
|
Manuel MM, Feng S, Yen K, Patel F. The agitated pediatric patient located in the emergency department: The APPLIED observational study. J Am Coll Emerg Physicians Open 2022; 3:e12766. [PMID: 35769845 PMCID: PMC9208717 DOI: 10.1002/emp2.12766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/14/2022] [Accepted: 05/26/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3‐year‐period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, InternationalClassification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non‐Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2–2.7), but not restrained (aOR, 0.8; 95% CI, 0.3–1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5–3.3), autism (aOR, 2.9; 95% CI, 1.9–4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2–2.5), psychosis (aOR, 14.3; 95% CI, 2.5–271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2–3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0–3.5). Depression (aOR, 0.4; 95% CI, 0.3–0.5) and suicidality (aOR, 0.2; 95% CI, 0.1–0.3) were protective against agitation and restraint use. Conclusion Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.
Collapse
Affiliation(s)
- Matthias M. Manuel
- Division of Emergency Medicine Department of Pediatrics University of Texas Southwestern Medical Center/Children's Health Dallas Texas USA
| | - Sing‐Yi Feng
- Division of Emergency Medicine Department of Pediatrics University of Texas Southwestern Medical Center/Children's Health Dallas Texas USA
- North Texas Poison Center Parkland Health and Hospital System Dallas Texas USA
| | - Kenneth Yen
- Division of Emergency Medicine Department of Pediatrics University of Texas Southwestern Medical Center/Children's Health Dallas Texas USA
| | | |
Collapse
|
48
|
Bailey JA, Jacoby SF, Hall EC, Khatri U, Whitehorn G, Kaufman EJ. Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury. CURRENT TRAUMA REPORTS 2022; 8:105-112. [PMID: 35578594 PMCID: PMC9096065 DOI: 10.1007/s40719-022-00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review
Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care. Recent Findings Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential. Summary A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.
Collapse
Affiliation(s)
- Joanelle A. Bailey
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Sara F. Jacoby
- University of Pennsylvania School of Nursing, Philadelphia, PA USA
| | - Erin C. Hall
- Trauma Surgery and Critical Care Medicine, MedStar Health, Washington, DC USA
| | - Utsha Khatri
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Gregory Whitehorn
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| |
Collapse
|
49
|
Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open 2022; 12:e059876. [PMID: 35545394 PMCID: PMC9096567 DOI: 10.1136/bmjopen-2021-059876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Lauren J Crispino
- Department of Emergency Medicine, Virginia Tech Carilion Clinic, Roanoke, Virginia, USA
| | - John B Parker
- Department of Emergency Medicine, Coliseum Health System, Macon, Georgia, USA
| | | | - Leah Robinson
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne DeSanto Iennaco
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Nursing, Orange, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Dartmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Medical School, Worchester, Massachusetts, USA
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
50
|
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
|