Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice

Abstract

ObjectivesAgitation, 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.DesignQualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events.SettingTwo EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital.ParticipantsWe 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.ResultsThree 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.ConclusionsAgitation 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.

Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status

“…Third, it is also possible that the disproportionate involvement of police in the transport of Black patients creates a perception of threat among the treatment team. Implicit or explicit biases among health care professionals and law enforcement could influence the risk-benefit decisions made by clinicians regarding the use of physical restraint . Medical resources might even be delayed based on a patient’s actual or perceived criminality .…”

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

“…We will design ED-TREAT for use by staff members who work mostly closely with agitated patients in the ED 7 35 46–48. These consist of ED physicians, nurses and patient care technicians.…”

“…An estimated 1.7 million agitation episodes occur annually in EDs across the USA alone 5 6. When an individual becomes agitated, they may cause harm to themselves, hospital staff, and property 7–9. Rapid management of agitation is imperative and use of physical restraint may be necessary to facilitate patient assessment and prevent injury 5.…”

Curated collections for educators: Nine key articles and article series for teaching qualitative research methods

“…Qualitative methods can lead to better understanding of the patient experience and thus provide valuable insights not accessible through quantitative methods. For example, qualitative methods have been used to better understand nonquantitative factors influencing the results of medical interventions 11 and develop approaches that better meet patients’ needs 12 …”

“…For example, qualitative methods have been used to better understand nonquantitative factors influencing the results of medical interventions 11 and develop approaches that better meet patients' needs. 12 Despite the significant potential impact of well-designed and well-conducted qualitative research studies in many fields of health care, 13 significantly fewer qualitative research studies are published compared to quantitative studies. 14,15 This may in part be due to low prioritization of qualitative research at many medical science journals 16 and lack of familiarity among physicians and health science researchers with qualitative methods.…”