Using a single-item rating scale as a psychiatric behavioral management triage tool in the emergency department.

INTRODUCTION: Proper monitoring of patients' behavior is essential for effective treatment and efficient disposition of psychiatric cases in the adult emergency department. The goal of the current study was to examine an attempt to implement the Behavioral Activity Rating Scale, an existing single-item measure of behavioral activity, as part of a behavioral management triage strategy for psychiatric patients in an emergency department. METHODS: For the period beginning approximately 2 months after use of the behavioral activity measure was initiated in the emergency department, charts from 284 consecutive patients who presented to the department with a chief complaint that was psychiatric in nature were reviewed. RESULTS: Level of adoption of the measure by emergency nurses was lower than desired; only 46% of charts reviewed contained a behavioral activity rating. Ratings were less likely to be recorded during the night shift than during other shifts. As predicted, ratings indicative of elevated behavioral activity were associated with physician orders for formal behavioral management (ie, intramuscular, intravenous, or orally dissolving sedating medications or physical restraint). DISCUSSION: The findings of this study suggest that a single-item behavioral activity measure may be an efficient, effective, and discreet way for emergency nursing staff to communicate with one another and with physicians about psychiatric patients in need of behavioral management in adult emergency departments. The findings also suggest that a broad implementation approach is needed to achieve desired levels of adoption by emergency nursing staff.

Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup.

Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units, and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA (Best practices in Evaluation and Treatment of Agitation) is noncoercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior. In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment primarily of acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions.

The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup.

Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause of the agitation. If agitation results from a delirium or other medical condition, clinicians should first attempt to treat the underlying cause instead of simply medicating with antipsychotics or benzodiazepines.

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the "10 domains of de-escalation."