Use of sedatives and restraints for treatment of agitation in the emergency department

Wong, Ambrose H.; Crispino, Lauren; Parker, John B.; McVaney, Caitlin; Rosenberg, Alana; Ray, Jessica; Whitfill, Travis; Iennaco, Joanne; Bernstein, Steven L.

doi:10.1016/j.ajem.2018.12.027

Cited by 10 publications

(21 citation statements)

References 16 publications

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“…Eligible individuals were adult ED patients who had been restrained during a visit to either hospital site. We identified these patients either through a convenience sample of visits that contained an ED restraint order between March 2016 and February 2018 or during a prospective cohort study 11 of agitation events that occurred in either study site ED between June 2017 and August 2017. Participants received $50 in compensation for completion of a JAMA Network Open | Emergency Medicine survey and interview.…”

Section: Participants and Settingmentioning

confidence: 99%

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

et al. 2020

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IMPORTANCE Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. OBJECTIVE To characterize how individuals experience episodes of physical restraint during their ED visits. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast MAIN OUTCOMES AND MEASURES Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED. RESULTS Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%]non-Hispanic). The time between the patient's last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. CONCLUSIONS AND RELEVANCEIn this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm. Findings This qualitative study of 25 patients who were physically restrained in the emergency department found the 3 following major themes: harmful experiences of restraint use and care provision, diverse and complex personal contexts affecting visits to the emergency department, and challenges in resolving their restraint experiences, leading to negative consequences on well-being. Meaning Results of this study suggest that the participants in this study desired compassion and therapeutic engagement during physical restraint, warranting further attention to patientcentered approaches and coercionreduction techniques that fit with the needs of emergency care.

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Section: Participants and Settingmentioning

confidence: 99%

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

et al. 2020

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“…Agitated patients often have substance use disorders, serious mental illnesses, and disadvantaged socioeconomic backgrounds, representing the most marginalized populations presenting to the ED. [ 49 – 51 ] Unfortunately, these patients can be challenging to properly diagnose and treat due to difficulties in obtaining accurate histories and physical exams and establishing therapeutic rapport during decompensation of their underlying conditions. In addition, implicit bias and stigma against mental illness and substance use can further impede objective and patient-centered management decisions [ 25 , 52 , 53 ], and these clinician sentiments may heighten in the face of learned helplessness and emotional exhaustion from repeated exposure to workplace violence [ 54 ].…”

Section: Discussionmentioning

confidence: 99%

A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

Wong

Sabounchi

Roncallo

et al. 2022

BMC Health Serv Res

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Background Over 1.7 million episodes of agitation occur annually across the United States in emergency departments (EDs), some of which lead to workplace assaults on clinicians and require invasive methods like physical restraints to maintain staff and patient safety. Recent studies demonstrated that experiences of workplace violence contribute to symptoms of burnout, which may impact future decisions regarding use of physical restraints on agitated patients. To capture the dynamic interactions between clinicians and agitated patients under their care, we applied qualitative system dynamics methods to develop a model that describes feedback mechanisms of clinician burnout and the use of physical restraints to manage agitation. Methods We convened an interprofessional panel of clinician stakeholders and agitation experts for a series of model building sessions to develop the current model. The panel derived the final version of our model over ten sessions of iterative refinement and modification, each lasting approximately three to four hours. We incorporated findings from prior studies on agitation and burnout related to workplace violence, identifying interpersonal and psychological factors likely to influence our outcomes of interest to form the basis of our model. Results The final model resulted in five main sets of feedback loops that describe key narratives regarding the relationship between clinician burnout and agitated patients becoming physically restrained: (1) use of restraints decreases agitation and risk of assault, leading to increased perceptions of safety and decreasing use of restraints in a balancing feedback loop which stabilizes the system; (2) clinician stress leads to a perception of decreased safety and lower threshold to restrain, causing more stress in a negatively reinforcing loop; (3) clinician burnout leads to a decreased perception of colleague support which leads to more burnout in a negatively reinforcing loop; (4) clinician burnout leads to negative perceptions of patient intent during agitation, thus lowering threshold to restrain and leading to higher task load, more likelihood of workplace assaults, and higher burnout in a negatively reinforcing loop; and (5) mutual trust between clinicians causes increased perceptions of safety and improved team control, leading to decreased clinician stress and further increased mutual trust in a positively reinforcing loop. Conclusions Our system dynamics approach led to the development of a robust qualitative model that illustrates a number of important feedback cycles that underly the relationships between clinician experiences of workplace violence, stress and burnout, and impact on decisions to physically restrain agitated patients. This work identifies potential opportunities at multiple targets to break negatively reinforcing cycles and support positive influences on safety for both clinicians and patients in the face of physical danger.

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“…The major concern about this case was the level of aggression shown by the patient, which could not be managed by the medications given in the ED. Of note, 50% of medical providers suffer physical violence at some point in their careers [7,8]. A survey showed that two-thirds of physicians have minimal or no training in the management of an agitated patient [7].…”

Section: Discussionmentioning

confidence: 99%

An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department

Crane¹,

Aguiar²,

Nielson³

2022

Cureus

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We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.

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Use of sedatives and restraints for treatment of agitation in the emergency department

Cited by 10 publications

References 16 publications

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

Experiences of Individuals Who Were Physically Restrained in the Emergency Department

A qualitative system dynamics model for effects of workplace violence and clinician burnout on agitation management in the emergency department

An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department

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