Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup

Abstract

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Simulation-Based Training for Residents in the Management of Acute Agitation: A Cluster Randomized Controlled Trial

“…The participants were scored on 11 categories including obtaining information from nursing staff, maintaining personal safety, assessing the patient, attitude, empathy, selection and timing of oral medications offered, response to escalation, when to call security, when to order a restraint, and intramuscular medication selection. These categories were determined by consensus discussion among a panel of experts and are consistent with published guidelines on best practices in the management of agitation [12][13][14][15][16][17]. In each category, participants were scored between 0 and 5 with specific behavioral anchors.…”

“…The participants had the opportunity to practice a number of skills, including obtaining key clinical information from the nurse, attending to safety, performing a focused interview of the patient, employing appropriate verbal deescalation techniques, deciding when to call for security, offering oral medications, and ultimately ordering a physical restraint with intramuscular medications. Consensus guidelines were used to determine the appropriate steps in the assessment and management of an agitated patient [12][13][14][15][16][17].…”

Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use

“…The patient was considered to be agitated if clinician notes specifically mentioned that the patient was "agitated," "disruptive," or "homicidal," or if, following expert consensus definitions, the patient had increased verbal or motor activity [20]. The timing of the mental health hold was calculated relative to the triage time and was considered as placed early in the ED stay if mental health hold time minus triage time was less than 60 minutes.…”

Ketamine Use for Acute Agitation in the Emergency Department

“…Patients were included if ketamine was administered as treatment for acute agitation. Agitation was defined, following recent American Association for Emergency Psychiatry BETA project guidelines, as ''an extreme form of arousal that is associated with increased verbal and motor activity'' (25). This definition was operationally adapted for use by including situations where the patient was noted to be physically aggressive with staff, require restraints, or have increased verbal/motor activity interfering with treatment.…”