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

Abstract

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.”

The effect of aggression management training programmes for nursing staff and students working in an acute hospital setting. A narrative review of current literature

“…Aggressive episodes develop over five phases (trigger, escalation, crisis, plateau and post crisis depression phase) (23). Detecting aggression, intervening and de-escalating at an early stage are essential (24). Regular aggression management (AM) training aims to increase staff knowledge and foster interactional competencies, such as preventing and de-escalating PVA verbally and non-verbally in a non-coercive, collaborative, and interactional approach (25).…”

Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies

“…113 -116 Although consensus is that verbal restraint is preferable to chemical or physical restraint, 117 reviews of the literature find primarily case studies, with a paucity of rigorous studies of verbal restraint, and little on specific strategies or efficacy. 113,118 For example, although a study by Jonikas et al found a decrease in restraint use, it was not clear whether the decrease was attributable to staff training in de-escalation techniques or to crisis intervention training, which occurred at the same time. 119 Other protocols emphasize the importance of prevention in behavior management protocols.…”

“…112 Four guiding principles for working with agitated patients are as follows: (1) maximizing the safety of the patient and treating staff; (2) assisting the patient in managing his or her emotions and maintaining or regaining control of his or her behavior; (3) using the least restrictive, age-appropriate methods of restraint possible; and (4) minimizing coercive interventions that may exacerbate agitation. 113 …”

“…115,120 Detailed in Table 2 are Fishkind's "Ten Commandments of De-escalation, " which incorporate practical, commonly used verbal restraint strategies. 112 -114, 121 -123 Other strategies that may improve the chances of successful de-escalation include a calming physical environment with decreased sensory stimulation, rooms that have been "safety-proofed" (ie, removal or securing of objects that could be used as weapons) or close monitoring if this is not possible, 113 modifying or eliminating triggers of agitation (eg, an argumentative acquaintance, friend, or family or staff member, a long ED wait time), 117,124,125 and staff training in behavioral emergencies. 126,127 A child life specialist may also be an excellent resource to help calm an agitated child.…”

Ketamine Use for Acute Agitation in the Emergency Department

“…Causes of ED-based agitation are numerous, ranging from psychosis to intoxication (2)(3)(4)(5)8). Although verbal de-escalation is recommended as first-line treatment, in some cases this can be ineffective and medication administration may be required to prevent these patients from harming themselves or others (10,12). However, many of these medications have a relatively slow onset, require empiric dosing, and often require additional medication for calming (10,13).…”