Keep Emergency for Emergencies? Reframing the basic assumption

Emergency departments (ED) are open 24 hours a day, 365 days a year. Health conditions can develop or worsen at a moments’ notice, making the ED a necessary safety net for even the best healthcare systems. However, the very characteristic that makes the ED essential also leaves it open to abuse. When there is nowhere else to go it is an attractive location to bring the intoxicated, the homeless, the destitute – the people with nowhere else to go. Worse, occasionally it can seem like the ED is overwhelmed by seemingly healthy patients who are not patient at all.

These realities have led to the increasing prevalence of “patient-blaming.” A popular administrative response to ED overcrowding, especially in publicly funded healthcare systems, seems to be to tell patients to stay away unless they have a “true emergency.” Perhaps the best example is the Australian video “Keep Emergency for Emergencies” that recently went viral.

It implies that ED overcrowding is the result of low-acuity patients with “fake emergencies” – a conclusion that has been well-studied and found to be patently untrue [1,2,3] – rather than a systemic problem resulting from the health system’s inability to predict and meet demand. My own health region has not been immune from this line of thinking, having recently instructed patients on “proper use” of the ED.

The Canadian Association of Emergency Physicians (CAEP) frames ED overcrowding as a problem of ‘Access Block’:

“(Access block is) the inability of admitted patients to access in-patient beds from the ED.”

and asserts quite bluntly that:

“Contrary to popular perceptions, ED overcrowding is not caused by inappropriate use of ED’s, or by high numbers of lower acuity patients presenting to the ED”

While this does not make intuitive sense, it is true because low-acuity patients do not require a hospital bed and can generally be assessed and discharged quickly without contributing substantively to access block.

The problems with “fake” emergencies

It would be easy to conclude that having fewer patients in an overcrowded ED would be beneficial regardless of whether or not they created the problem. If that were the case this type of public service announcement would serve an important purpose. However, I think there are three problems with this conclusion.

First, sick patients often do not realize that they are sick. Over the past 6 months I can think of multiple stoic patients that I saw for general malaise (a condition that is not on any lists of “true emergencies”) that had serious pathology (e.g. myocardial infarction, hyperkalemia, diabetic ketoacidosis) requiring inpatient treatment. Our patients do not have the benefit of emergency health care training to help them determine what an emergency is and what it is not. In response to public campaigns inspired by the commercial above, these patients would have likely stayed at home because they “didn’t want to be a bother.” This decision would have been severely detrimental to both their health and the ultimate cost of their care.

Second, it puts the blame for overcrowding on our patients rather than our system. Beyond being unfair (and untrue!), this response has the potential to sour the attitude of already stressed healthcare providers towards low-acuity patients. Those that buy into this message could see patients as the problem, rather than our purpose, leading to dissatisfaction and poor care.

Third, it gets in the way of good care. In my (admittedly very short) emergency medicine career I have found that many of the patients who are perceived as abusing the system (and there certainly are some) do not think they are, do not want to be, or came in for another reason. Think of the patient with frostnip (who came in because he was worried that his ear was going to fall off), the recent immigrant with the flu (who did not know how to access primary healthcare), or the women with a headache (who was too scared to tell us that her spouse is beating her). In each case the assumption that these patients are “abusing the system” would result in worse outcomes due to missed opportunities for education and/or intervention.

New Concept: The Basic Assumption

Last year I attended the Comprehensive Instructor Workshop at the Institute for Medical Simulation, a course that puts substantial focus on the art of debriefing learners following simulation. One of the primary tenets of their course is instilling “The Basic Assumption” into attendees.

The Basic Assumption

“We believe that everyone participating in activities is intelligent, capable, cares about doing their best, and wants to improve.”

While at first glance this seems like a fairly standard motherhood statement, after conducting simulation debrief after debrief I have learned its value. Facilitators vary widely in their debrief style, but it is always clear that the best of them believe in the integrity of their learners. Their debriefs are more enlightening, honest, and educational as a result. Seeing this led me to make The Basic Assumption a central tenet of my educational philosophy.

Combining this with my observations of some of my most admired mentors led me to a striking realization: in the same way excellent facilitators assume the best about their learners, excellent emergency physicians assume the best about their patients. Noting this, I rewrote The Basic Assumption to change its focus from learners to emergency department patients.

The Basic Assumption about Emergency Department Patients

“We believe that every patient presenting to the ED is honest, cares about their health, and needs our assistance.”

In the same way that this leads to optimal educational interactions with learners, believing in the integrity of our ED patients will lead to better care for them and a longer and more satisfying career for me. Just as the Center for Medical Simulation embraces The Basic Assumption for their trainees, I would love to see ED’s embrace it for their patients.

Conclusion

Working in an emergency department is a difficult job. Even when the department is spilling into the nearby Tim Hortons we do not turn anyone away. After resuscitating a young trauma patient it can be difficult to have patience for a low-acuity patient requesting a prescription refill. However, a better understanding of the underlying causes of access block and ED overcrowding can help. I am encouraged to know that my health region will no longer ask the public to avoid the ED. Instead, we are working to find ways to connect patients with the resources they need – even if it means coming to the ED while we figure it out.

I hope backlash against the inaccurate and harmful “Keep Emergency for Emergencies” commercial and campaign will lead heath care leaders to a similar conclusion in Australia. After all, “these patients are honest, they care about their health and they need our assistance.” If we can find it in ourselves to greet each and every patient with this assumption, I believe we will be more satisfied with our jobs and provide better care to our patients.

Please share this post if you agree with its sentiments as BoringEM does not have the budget to make such a snazzy video in response!

Expert Peer Review: This post was reviewed by Drs. James Stempien (@docstemp) and Mark Wahba (@mywahbaMD).

Further Reading

  1. Affleck A, Parks P, Drummond D, Rowe BH & Ovens HJ. (2013). CAEP position statement: Emergency department overcrowding and access block. Canadian Journal of Emergency Medicine, 15(6), 359-370. DOI 10.2310/8000.CAEPPS [Link]
  2. Canadian Health Services Research Foundation. (2009). Myth: Emergency Room Overcrowding is caused by Non-urgent Cases. [Link]
  3. Picard A. (2015). What’s really to blame for ER congestion?  The Globe and Mail. [Link]

Author information

Brent Thoma
Editor in Chief at BoringEM
Emergency Medicine Resident at the University of Saskatchewan, wannabe Medical Educator, Blogging Geek. + Brent Thoma

The post Keep Emergency for Emergencies? Reframing the basic assumption appeared first on BoringEM and was written by Brent Thoma.

Boring Question | Does this pediatric patient require a hard cast ?

It is a typical day in Fast Track, and you have a 8 year old who fell off their skateboard with a distal radius fracture that is commonly referred to as a “Buckle fracture” (AKA torus fracture). The child is very upset and concerned about having their arm splinted / casted given that they plan on spending a lot of time in a swimming pool this summer. You wonder, does this patient require an unremovable splint in the ED?

Fortunately, for your patient, the literature is on their side. In one study of 87 patients (age 6 to 15 years) with distal radius and/or ulna buckle fractures treatment with a short arm cast for 3 weeks (45 patients) was compared with a removable splint (42 patients). Scoring via the Activities Scale for Kids [1] at days 14 and 20 suggested better physical functioning and less difficulty with activities in the removable splint group [2]. A second study on buckle fractures allocated 18 pediatric patients to a removable bandage [ie, an ACE wrap] and 21 to plaster cast. Results strongly favored the removable bandage with excellent range of motion in the first week and no reported adverse effects [3]. A third study evaluated 66 adult patients with minimally displaced distal radial fractures that were randomly assigned to either a plaster cast or removable splint. Cast satisfaction, cast problems and the functional assessment score at 6 weeks all favored the removable splint [4].

Many of you may be wondering about patient compliance and potential complications. Well, in a meta-analysis [5] encompassing 455 participants, there were no refractures reported during the healing period regardless of degree of immobilization, with improved function, patient acceptance, and caregiver satisfaction with the use of removable splints.

In fact, the same can be said for Salter Harris Class I & II ankle fractures. In a study of 54 children treated with a removable ankle brace vs 50 casted children, 81% of those in a removable ankle brace were back at baseline activities in 4 weeks compared to just 60% of those casted [6]. A second study of 40 patients with Lauge-Hansen supination-eversion, stage II ankle fractures compared a removable air stirrup splint to casting; this study demostrated a significant improvement in early patient comfort, post-fracture swelling, range of ankle motion at union, and time to full rehabilitation with the removable splint [7]. In a third study that looked at splinting vs casting of 62 pediatric sprained ankles, absenteeism and the parents’ absenteeism were higher in the casted group [8].

After explaining to the parents that non-displaced buckle fractures heal quite well on their own, that refractures are rare, and that functionality is regained sooner with a removable splint, you proceed to place a removable Velcro wrist splint, recommend rest, ice, elevation, NSAIDs, and primary care follow up in 1-2 weeks. The patient proceeds to do well without complications, and is swimming without sequelae in a matter of weeks.

References

  1. Activities Scale for Kids. Website. Available at: http://www.activitiesscaleforkids.com/
  2. Plint, A. C., Perry, J. J., Correll, R., Gaboury, I., & Lawton, L. (2006). A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.Pediatrics117(3), 691-697.
  3. West, S., Andrews, J., Bebbington, A., Ennis, O., & Alderman, P. (2005). Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. Journal of Pediatric Orthopaedics25(3), 322-325.
  4. O’connor, D., Mullett, H., Doyle, M., Mofidi, A., Kutty, S., & O’SULLIVAN, M. (2003). Minimally displaced Colles’ fractures: a prospective randomized trial of treatment with a wrist splint or a plaster castJournal of Hand Surgery (British and European Volume)28(1), 50-53.
  5. Kennedy, S. A., Slobogean, G. P., & Mulpuri, K. (2010). Does degree of immobilization influence refracture rate in the forearm buckle fracture?.Journal of Pediatric Orthopaedics B19(1), 77-81.
  6. Boutis, K., Willan, A. R., Babyn, P., Narayanan, U. G., Alman, B., & Schuh, S. (2007). A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fracturesPediatrics119(6), e1256-e1263.
  7. Stuart, P. R., Brumby, C., & Smith, S. R. (1989). Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fracturesInjury20(6), 323-326.
  8. Launay, F., Barrau, K., Simeoni, M. C., Jouve, J. L., Bollini, G., & Auquier, P. (2008). [Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]Archives de pediatrie: organe officiel de la Societe francaise de pediatrie15(12), 1749-1755.

Reviewing with the Staff | Damian Roland

In all aspects of medicine translating evidence into practice is a slow process. Paediatric Emergency Medicine is no exception. In this short review the evidence for using splints rather than casts is presented. A Cochrane review six years ago highlighted their potential benefit however only slowly are children’s emergency departments using this approach to improve the patient experience and reduce costs.

The challenge here, ignoring the inherent face validity, is the balance between  improved patient experience, for which there is good evidence, and potential negative outcomes. The authors don’t describe the quality of the papers that are reviewed: what were the biases, and were they sponsored by splint manufacturers for instance.

This conundrum is a persistent research challenge – but our hospital for one (Leicester Royal Infirmary, UK) has been using splints for buckle fractures for some time. :)

Author information

Patrick Bafuma
Patrick Bafuma

The post Boring Question | Does this pediatric patient require a hard cast ? appeared first on BoringEM and was written by Patrick Bafuma.

Boring Question | Does this pediatric patient require a hard cast ?

It is a typical day in Fast Track, and you have a 8 year old who fell off their skateboard with a distal radius fracture that is commonly referred to as a “Buckle fracture” (AKA torus fracture). The child is very upset and concerned about having their arm splinted / casted given that they plan on spending a lot of time in a swimming pool this summer. You wonder, does this patient require an unremovable splint in the ED?

Fortunately, for your patient, the literature is on their side. In one study of 87 patients (age 6 to 15 years) with distal radius and/or ulna buckle fractures treatment with a short arm cast for 3 weeks (45 patients) was compared with a removable splint (42 patients). Scoring via the Activities Scale for Kids [1] at days 14 and 20 suggested better physical functioning and less difficulty with activities in the removable splint group [2]. A second study on buckle fractures allocated 18 pediatric patients to a removable bandage [ie, an ACE wrap] and 21 to plaster cast. Results strongly favored the removable bandage with excellent range of motion in the first week and no reported adverse effects [3]. A third study evaluated 66 adult patients with minimally displaced distal radial fractures that were randomly assigned to either a plaster cast or removable splint. Cast satisfaction, cast problems and the functional assessment score at 6 weeks all favored the removable splint [4].

Many of you may be wondering about patient compliance and potential complications. Well, in a meta-analysis [5] encompassing 455 participants, there were no refractures reported during the healing period regardless of degree of immobilization, with improved function, patient acceptance, and caregiver satisfaction with the use of removable splints.

In fact, the same can be said for Salter Harris Class I & II ankle fractures. In a study of 54 children treated with a removable ankle brace vs 50 casted children, 81% of those in a removable ankle brace were back at baseline activities in 4 weeks compared to just 60% of those casted [6]. A second study of 40 patients with Lauge-Hansen supination-eversion, stage II ankle fractures compared a removable air stirrup splint to casting; this study demostrated a significant improvement in early patient comfort, post-fracture swelling, range of ankle motion at union, and time to full rehabilitation with the removable splint [7]. In a third study that looked at splinting vs casting of 62 pediatric sprained ankles, absenteeism and the parents’ absenteeism were higher in the casted group [8].

After explaining to the parents that non-displaced buckle fractures heal quite well on their own, that refractures are rare, and that functionality is regained sooner with a removable splint, you proceed to place a removable Velcro wrist splint, recommend rest, ice, elevation, NSAIDs, and primary care follow up in 1-2 weeks. The patient proceeds to do well without complications, and is swimming without sequelae in a matter of weeks.

References

  1. Activities Scale for Kids. Website. Available at: http://www.activitiesscaleforkids.com/
  2. Plint, A. C., Perry, J. J., Correll, R., Gaboury, I., & Lawton, L. (2006). A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.Pediatrics117(3), 691-697.
  3. West, S., Andrews, J., Bebbington, A., Ennis, O., & Alderman, P. (2005). Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. Journal of Pediatric Orthopaedics25(3), 322-325.
  4. O’connor, D., Mullett, H., Doyle, M., Mofidi, A., Kutty, S., & O’SULLIVAN, M. (2003). Minimally displaced Colles’ fractures: a prospective randomized trial of treatment with a wrist splint or a plaster castJournal of Hand Surgery (British and European Volume)28(1), 50-53.
  5. Kennedy, S. A., Slobogean, G. P., & Mulpuri, K. (2010). Does degree of immobilization influence refracture rate in the forearm buckle fracture?.Journal of Pediatric Orthopaedics B19(1), 77-81.
  6. Boutis, K., Willan, A. R., Babyn, P., Narayanan, U. G., Alman, B., & Schuh, S. (2007). A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fracturesPediatrics119(6), e1256-e1263.
  7. Stuart, P. R., Brumby, C., & Smith, S. R. (1989). Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fracturesInjury20(6), 323-326.
  8. Launay, F., Barrau, K., Simeoni, M. C., Jouve, J. L., Bollini, G., & Auquier, P. (2008). [Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]Archives de pediatrie: organe officiel de la Societe francaise de pediatrie15(12), 1749-1755.

Reviewing with the Staff | Damian Roland

In all aspects of medicine translating evidence into practice is a slow process. Paediatric Emergency Medicine is no exception. In this short review the evidence for using splints rather than casts is presented. A Cochrane review six years ago highlighted their potential benefit however only slowly are children’s emergency departments using this approach to improve the patient experience and reduce costs.

The challenge here, ignoring the inherent face validity, is the balance between  improved patient experience, for which there is good evidence, and potential negative outcomes. The authors don’t describe the quality of the papers that are reviewed: what were the biases, and were they sponsored by splint manufacturers for instance.

This conundrum is a persistent research challenge – but our hospital for one (Leicester Royal Infirmary, UK) has been using splints for buckle fractures for some time. :)

Author information

Patrick Bafuma
Patrick Bafuma

The post Boring Question | Does this pediatric patient require a hard cast ? appeared first on BoringEM and was written by Patrick Bafuma.

KT Evidence Bite: Rapid blood pressure lowering in intracerebral hemorrhage

Editor’s note: This is a series based on work done by three physicians (Patrick ArchambaultTim Chaplin, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: Rapid blood pressure lowering in patients with acute intracerebral hemorrhage

Citation: 

Anderson, C. S., Heeley, E., Huang, Y., Wang, J., Stapf, C., Delcourt, C., … & Chalmers, J. (2013). Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. New England Journal of Medicine368(25), 2355-2365. doi: 10.1056/NEJMoa1214609

Nickname of study: 
INTERACT-2

Summarized by: Teresa Chan
Reviewed by:Patrick Archambault & Tim Chaplin

Clinical Question

Does rapid lowering of blood pressure improve the outcome in patients with intracerebral haemorrhage?

PopulationPatients included had:

1) spontaneous intracerebral haemorrhage within the previous 6 hours
AND
2) Elevated Systolic BP (i.e. BP between 150-220 mmHg)
InterventionLower BP to target systolic level of < 140 mmHg within 1 hour with agents of physician’s choosing
Control Lower BP to target systolic level of < 180 mmHg (per guidelines) with agents of physician’s choosing
OutcomePrimary Outcome: Death or Major Disability (modified Rankin score of 3-6) at 90 days

Methods

This was a multicenter, randomized controlled trial. Patients were randomized to low target (>140) or high target (<180) and unblinded physicians then chose treatments to meet these targets. Primary outcomes were death and severe disability (as evaluated by the modified Rankin score) Intention to treat analysis was performed.

Results

719 of 1382 patients (52%) of those receiving intensive treatment vs. 785 of 1412 (55.6%) patients in guideline-targets had death or severe disability. This yielded an odds ratio for death or severe disability of 0.87 (95% CI 9.75-1.01 p=0.06) favouring the lower target group.

The performance of some mathematical acrobatics (bimodal ‘ordinal’ analysis of the patients stratifying them by their modified Rankin Score) yielded a significant difference (p=0.04) between the lower and higher target.

Conclusions

“In patients with intracerebral haemorrhage, intensive lowering of blood pressure did not result in a significant reduction in the rate of the primary outcome of death or severe disability. An ordinal analysis of modified Rankin scores indicated improved functional outcomes with intensive lowering of blood pressure.”

Take Home Point

There is no difference in ICH patients if you intensively lower their BP to targets of 140mmHg vs. the guidelines-suggested target of 180 mmHg.

There may be some interaction between BP targets and severity of outcomes as per the modified Rankin Score, but it is unclear if there is a clinically significant difference or merely a statistical anomaly.

EBM Considerations

  • Lack of blinding: Of note, half of the patients in the guideline group had an SBP > 180mmHg at baseline, and only 303 of them received ANY anti-hypertensive agent in the first group. This is concerning since the intervention group received IV therapy was much more common (p < 0.0001). This difference could have been associated with a lack of blinding, which we appreciate would have been difficult to do.
  • Multiple comparisons: The authors completed many comparisons in this study between the two groups, and the only difference in outcome they were able to find was in the ordinal comparison (which lumps several comparisons into one), and yet their significance threshold was only set at p=0.05. While the Bonferroni correction is likely too conservative in its adjustments, some sort of correction for the number of comparisons might have been warranted.
  • External validity: The majority of patients (~60%) in this study were males in China. This demographic is not representative of the population seen in Canadian emergency departments and as such external validity may be compromised in our context.

To learn more about blood pressure in intracerebral hemorrhage check out:

To download a copy of this summary click here NRC – BoringEM – The INTERACT2 study.

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bite: Rapid blood pressure lowering in intracerebral hemorrhage appeared first on BoringEM and was written by Eve Purdy.

Violence and Agitation in the Emergency Department

The management of agitation in the ED can be a distressing experience. The first time you encounter an upset, angry, or violent patient can feel overwhelming and uncomfortable. Rapid decision-making is often necessary; decisions may be based on limited information during an unfolding situation. Arming yourself with basic guidelines, a supportive team, and an opportunity for debrief can be helpful in the management of an unstable situation.

While data regarding prevalence is limited, many residents and medical students encounter agitated patients early in their training. A 2011 survey of emergency residents and attending physicians found that 78% experienced some form of workplace violence in the preceding 12 months [1]. For a variety of reasons – wait times, intoxicants, stressful situations, and acute medical concerns – emergency department workers experience significant rates of physical and verbal abuse [2].

Before a discussion of practical guidelines, it’s important to keep the following in mind: violence and agitation has a broad differential and patients may be in legitimate physical or emotional distress. Aggressive behaviours, such as yelling, spitting, hitting, and biting are means of communicating discomfort and the fact that, for whatever reason, this patient is not okay. This is particularly true of patients with developmental delays, who may be unable to articulate their concerns eloquently. To that end, keeping an open mind to medical issues that may be underlying a patient’s presentation is of the utmost importance..

Classifying Agitation

Agitated behavior, like many things in medicine, exists on a spectrum.

Table 1: Stages of Agitation and Response [3].

Level of Agitation Response
1. Agitation/Anxiety 1. Safety
2. Verbal Threats 2. Verbal De-escalation
3. Physical Threats 3. Physical Intervention
4. Resolution 4. Medication

Level 1: Agitation and Safety

At this stage, the goal is to ensure that the environment is safe. While not always possible in a busy emergency department, a quiet, low-stimulation environment with weighted furniture and objects that cannot be thrown or weaponized is ideal. Remove stethoscopes, lanyards and other neckwear that can be used to choke. Increase space between you and the patient, and position yourself so that both you and the patient have access to an escape route.

If possible, observe the patient’s behavior before the interaction. Read previous notes and assessments to determine if there is a history of violent behaviour. Determine if there is a language barrier. Talk to nursing staff who have already interacted with the patient. Has the patient been searched, or could they be carrying a weapon? Do not interview potentially dangerous patients alone or in an area where nobody can see or hear you.

Early signs of agitation include pacing, clenched fists, and increased volume and vocalization. It is important to recognize these early signs of behavioural escalation and intervene. Trust your instincts: if you experience discomfort, have another team member or security available as backup. Simply having security present, or even “around and visible” can prevent escalation of violent behaviour.

During your assessment, keep in mind that a patient may have been waiting a long time to be seen, and apologizing for the delay is an easy way to establish rapport. Convey that you are here to help and they are in a safe space. Do not approach quickly or from behind, staying in the patient’s line of sight. If the patient is not capable of reasoning with you because of substance use, psychosis, or cognitive concerns you may need to be more directive with your words. Finally, kindly asking the patient to be seated so that you can discuss their needs may be helpful.

Level 2: Verbal Threats and De-escalation

Verbal de-escalation involves engagement of your patient, establishing a collaborative relationship, and talking them down from an agitated state. Use verbal de-escalation to reduce the risk of harm to yourself, your team, and your patient [4]. The following consensus principles were developed as part of Project BETA (Best Practices in Evaluation and Treatment of Agitation)[4].

Table 2: Ten domains of de-escalation [5].
1. Respect Personal Space
2. Do not be provocative
3. Establish verbal contact
4. Be concise
5. Identify wants and feelings
6. Listen closely to what the patient is saying
7. Agree or agree to disagree
8. Lay down the law and set clear limits
9. Offer choices and optimism
10. Debrief the patient and staff

In fairness, you’re not going to be able to recite this in your head with an agitated patient threatening you and your team. Knowing general principles and acknowledging your own fear, anger, and emotional reaction is key in managing agitated patients.

Identify what the patient wants. Are they angry or sad because a need is not being met, or fearful of something bad happening? A psychotic patient may have bizarre or paranoid delusions that are nonsensical. Imagining that these delusions are true will help you to understand why the patient is afraid and what they need to feel safe [6]. Keep a safe distance and open stance so to not appear threatening or confrontational (hands visible, feet shoulder width apart, angled slightly to the side). Do not argue with the patient; never respond to an insult or raise your voice. It may even be helpful to lower your voice, as the patient is usually interested in what you have to say and may settle to listen. Keep sentences short. If there are multiple team members in the room, have one team lead the discussion.

Firmly and gently establish that you are in charge and you are uncomfortable or frightened by the patients behaviour. Ask direct questions about the possibility of violence. A patient may angrily demand to leave. The sense of powerlessness may be helped if you give choices, and you can offer a patient medication to help them feel calm. A patient with a psychotic history may know that an injection helps them feel in control and may, on occasion, ask for it.

Table 3: Helpful statements.
“I feel frightened when you are pacing – if you were able to sit down I bet I could help understand what is troubling you.”
“I can see you’re quite uncomfortable – may I offer you some medication to help you feel calm?”
“Mr. X, I need to give you some medication to help you stay in control – would you prefer to take a pill or a needle?”
“Mr. X, you are having a psychiatric emergency. I’m going to give you some emergency medication to help you feel calm and we will be here to keep you safe every step of the way”.

Level 3: Physical Threats and Intervention

Physical threats require physical intervention. Do not attempt to engage the patient. Security and/or police must be involved, which is why it may be helpful to have them present in advance. Restraint techniques will not be discussed here, but briefly: [7]

  • Physical restraint can be very unpleasant, and patients may be in significant distress. Physical restraint must be therapeutic, and not punitive.
  • Choose the least intrusive restraint that is sufficient for resolving the threat.
  • Continue to use verbal de-escalation and reassurance..
  • Chemical restraint should accompany physical restraint.
  • Restraints can be physically dangerous, and frequent monitoring and reassessment with a plan to reduce restraint is a necessity.

Level 4: Resolution and Medication

Broadly, pharmacologic management of agitation includes the use of benzodiazepines, antipsychotics, or both. Side effects of these medications are common and include extrapyramidal symptoms [EPS], QTc prolongation, and neuroleptic malignant syndrome [NMS]. Benzodiazepines are less likely to cause EPS but may exacerbate delirium and sedation. They may lead to respiratory depression and should be used with caution in patients with decreased pulmonary reserve [8]. For dosing, see the algorithm for pharmacologic management in the Wilson Paper [8].

Mild agitation that is not responding well to verbal de-escalation can often be managed with a low dose of oral or sub-lingual medication if a patient assents. In severe agitation where safety of your team is compromised, consider parenteral route administration.

Consider the etiology:

In agitated delirium, it is important to determine if ethanol or benzodiazepine withdrawal is suspected. In non-withdrawal delirium, benzodiazepines can exacerbate confusion or induce delirium, and treatment with antipsychotics is preferable. Patients at risk for delirium may also be at increased risk of extrapyramidal symptoms (EPS) and an atypical antipsychotic with lower D2 receptor blockade (loxapine, olanzapine) can be used first. Notably, withdrawal from these substances is life threatening and must be managed with benzodiazepines.

If you suspect ethanol intoxication, avoid further CNS depression; an antipsychotic can be helpful. Haloperidol has a low anticholinergic burden and is considered relatively non-sedating. Patients may calm to a point where they are able to sleep.

In patients with a known history of psychosis, an antipsychotic is often helpful. Atypical agents, such as olanzapine, can be more sedating. Haldoperidol and risperidone can be used, but a benzodiazepine may need to be added to increase sedation and reduce EPS. Olanzapine and lorazepam cannot be given together intramuscularly due to an increased risk of hypotension.[9]

Rapid tranquillization is defined as – well, it’s basically what it sounds like. Different historical schemes have been described, with patients receiving over 100 milligrams of haloperidol in some settings. Standard practice is now to use a combination of antipsychotic and a benzodiazepine, with additional benzodiazepine later as needed.

This is where the “5 and 2” combination comes from, as haloperidol (5mg) and lorazepam (2mg) can be mixed in the same syringe. This can be used q30 minutes-2 hours to a maximum of 20mg of haloperidol per day. [10] The onset of action for IM lorazepam is 10 minutes, and haloperidol is 30-60 minutes, so physical restraints may be needed in the interim. See table 4 for pharmacokinetic properties of medications used in chemical restraints.

Table 4: Pharmacokinetics of antipsychotics [8, 10].

  Initial Dose (mg) Onset (min) TMax (hr) T ½ (hr) Repeat Max Dose (24 hr, mg)
PO:
Risperidone 2 1 20-24 2 6
Olanzapine 5-10 5 hours 6 30 2 20
Haloperidol 5 30-60 0.5-1 12-36 q15 min. 20
Loxapine 12.5-25 30 1-3 1-14 q1hr 150
Lorazepam (SL) 2 10 20-30 min. 12-15 2 12
IM:
Olanzapine 10 15-45 15-45 min. 30 q20 min. 30
Haloperidol 5 30-60 0.5-1 12-36 q15 min 20
Loxapine 12.5-25 15-30 5 8-23 q1hr 150
Lorazepam 2 10 20-30 min. 12-15 2 12
IV:
Haloperidol 2-5 30-60 STAT 12-36 4 10 (NB. QTc prolongation)

Violence is a growing concern in busy emergency departments. You can respond effectively by understanding basic approaches. A team debrief following each episode will aid the process of learning and improvement.

Summary:

Keep the following points in mind:

  • Agitation has a broad differential and may be a patient’s only means of communicating physical distress.
  • Recognizing agitation early and de-escalating the situation is easier and less distressing than dealing with a physically violent patient. Prevention is essential.
  • Do not hesitate to have security or another team member present during your assessment.
  • Match the level of response with the level of agitation. Use physical restraint if necessary to protect yourself and your team, but the least amount possible and with close monitoring reassessment. Chemical restraints should be used in conjunction with physical restraint.

For another take on the agitated patient, be sure to check out previous BoringEM posts on this topic: The Agitated Patient in the ED: Assessment & Mild Agitation and The Agitated Patient in the ED: Moderate & Severe Agitation.

References:

  1. Behnam, M. et al. (2011). Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine, May; 40(5):565-79. doi: 10.1016/j.jemermed.2009.11.007.
  2. Taylor, J. L. and Rew, L. (2011). A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing, 20: 1072–1085. doi: 10.1111/j.1365-2702.2010.03342.x
  3. Lofchy, J. S. (2010), Chapter 15: Emergency Assessment In: Goldbloom, D. S. (2010). Psychiatric Clinic Skills, Revised 1st Ed. Toronto, ON: Center for Addiction and Mental Health
  1. Richmond, J. S. Berlin, J. S. Fishkind, A. B. Holloman, G. H. Zeller, S. L. Wilson, M. P. Aly Rifai, M. Ng, A. T. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 17-25
  2. Fishkind, A. (2002). Calming agitation with words, not drugs: 10 commandments for safety. Current Psych. 2002;1(4). Available at: http://www. currentpsychiatry.com/pdf/0104/0104_Fishkind.pdf.
  3. Elgin, S. H. (1999) Language in Emergency Medicine: A Verbal Self-Defense Handbook. Bloomington, IN: XLibris Corporation
  4. Knox, D. K. Holloman, G. H. Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 35-40
  5. Wilson, M. P. Pepper, D. Currier, G. W. Holloman, G. H. Feifel, D. (2012). The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 26-34
  6. Zacher, J. L. Roche-Desilets, J. (2005) Hypotension secondary to the combination of intramuscular olanzapine and intramuscular lorazepam. Journal of Clinical Psychiatry, Vol. 66(12):1614-1615
  7. Marder, S. R. (2006). A review of agitation in mental illness: treatment guidelines and current therapies. Journal of Clinical Psychiatry, Vol. 67 Suppl. 10:13-21

Author information

Bruce Alex Fage
Bruce Alex Fage
Bruce is a resident at the University of Toronto's Psychiatry program. He is a graduate of Queen's University (#qmed14). He is also involved in the www.psychable.ca project, which aims to bring #FOAMed to the Psychiatry world.

The post Violence and Agitation in the Emergency Department appeared first on BoringEM and was written by Bruce Alex Fage.

Violence and Agitation in the Emergency Department

The management of agitation in the ED can be a distressing experience. The first time you encounter an upset, angry, or violent patient can feel overwhelming and uncomfortable. Rapid decision-making is often necessary; decisions may be based on limited information during an unfolding situation. Arming yourself with basic guidelines, a supportive team, and an opportunity for debrief can be helpful in the management of an unstable situation.

While data regarding prevalence is limited, many residents and medical students encounter agitated patients early in their training. A 2011 survey of emergency residents and attending physicians found that 78% experienced some form of workplace violence in the preceding 12 months [1]. For a variety of reasons – wait times, intoxicants, stressful situations, and acute medical concerns – emergency department workers experience significant rates of physical and verbal abuse [2].

Before a discussion of practical guidelines, it’s important to keep the following in mind: violence and agitation has a broad differential and patients may be in legitimate physical or emotional distress. Aggressive behaviours, such as yelling, spitting, hitting, and biting are means of communicating discomfort and the fact that, for whatever reason, this patient is not okay. This is particularly true of patients with developmental delays, who may be unable to articulate their concerns eloquently. To that end, keeping an open mind to medical issues that may be underlying a patient’s presentation is of the utmost importance..

Classifying Agitation

Agitated behavior, like many things in medicine, exists on a spectrum.

Table 1: Stages of Agitation and Response [3].

Level of Agitation Response
1. Agitation/Anxiety 1. Safety
2. Verbal Threats 2. Verbal De-escalation
3. Physical Threats 3. Physical Intervention
4. Resolution 4. Medication

Level 1: Agitation and Safety

At this stage, the goal is to ensure that the environment is safe. While not always possible in a busy emergency department, a quiet, low-stimulation environment with weighted furniture and objects that cannot be thrown or weaponized is ideal. Remove stethoscopes, lanyards and other neckwear that can be used to choke. Increase space between you and the patient, and position yourself so that both you and the patient have access to an escape route.

If possible, observe the patient’s behavior before the interaction. Read previous notes and assessments to determine if there is a history of violent behaviour. Determine if there is a language barrier. Talk to nursing staff who have already interacted with the patient. Has the patient been searched, or could they be carrying a weapon? Do not interview potentially dangerous patients alone or in an area where nobody can see or hear you.

Early signs of agitation include pacing, clenched fists, and increased volume and vocalization. It is important to recognize these early signs of behavioural escalation and intervene. Trust your instincts: if you experience discomfort, have another team member or security available as backup. Simply having security present, or even “around and visible” can prevent escalation of violent behaviour.

During your assessment, keep in mind that a patient may have been waiting a long time to be seen, and apologizing for the delay is an easy way to establish rapport. Convey that you are here to help and they are in a safe space. Do not approach quickly or from behind, staying in the patient’s line of sight. If the patient is not capable of reasoning with you because of substance use, psychosis, or cognitive concerns you may need to be more directive with your words. Finally, kindly asking the patient to be seated so that you can discuss their needs may be helpful.

Level 2: Verbal Threats and De-escalation

Verbal de-escalation involves engagement of your patient, establishing a collaborative relationship, and talking them down from an agitated state. Use verbal de-escalation to reduce the risk of harm to yourself, your team, and your patient [4]. The following consensus principles were developed as part of Project BETA (Best Practices in Evaluation and Treatment of Agitation)[4].

Table 2: Ten domains of de-escalation [5].
1. Respect Personal Space
2. Do not be provocative
3. Establish verbal contact
4. Be concise
5. Identify wants and feelings
6. Listen closely to what the patient is saying
7. Agree or agree to disagree
8. Lay down the law and set clear limits
9. Offer choices and optimism
10. Debrief the patient and staff

In fairness, you’re not going to be able to recite this in your head with an agitated patient threatening you and your team. Knowing general principles and acknowledging your own fear, anger, and emotional reaction is key in managing agitated patients.

Identify what the patient wants. Are they angry or sad because a need is not being met, or fearful of something bad happening? A psychotic patient may have bizarre or paranoid delusions that are nonsensical. Imagining that these delusions are true will help you to understand why the patient is afraid and what they need to feel safe [6]. Keep a safe distance and open stance so to not appear threatening or confrontational (hands visible, feet shoulder width apart, angled slightly to the side). Do not argue with the patient; never respond to an insult or raise your voice. It may even be helpful to lower your voice, as the patient is usually interested in what you have to say and may settle to listen. Keep sentences short. If there are multiple team members in the room, have one team lead the discussion.

Firmly and gently establish that you are in charge and you are uncomfortable or frightened by the patients behaviour. Ask direct questions about the possibility of violence. A patient may angrily demand to leave. The sense of powerlessness may be helped if you give choices, and you can offer a patient medication to help them feel calm. A patient with a psychotic history may know that an injection helps them feel in control and may, on occasion, ask for it.

Table 3: Helpful statements.
“I feel frightened when you are pacing – if you were able to sit down I bet I could help understand what is troubling you.”
“I can see you’re quite uncomfortable – may I offer you some medication to help you feel calm?”
“Mr. X, I need to give you some medication to help you stay in control – would you prefer to take a pill or a needle?”
“Mr. X, you are having a psychiatric emergency. I’m going to give you some emergency medication to help you feel calm and we will be here to keep you safe every step of the way”.

Level 3: Physical Threats and Intervention

Physical threats require physical intervention. Do not attempt to engage the patient. Security and/or police must be involved, which is why it may be helpful to have them present in advance. Restraint techniques will not be discussed here, but briefly: [7]

  • Physical restraint can be very unpleasant, and patients may be in significant distress. Physical restraint must be therapeutic, and not punitive.
  • Choose the least intrusive restraint that is sufficient for resolving the threat.
  • Continue to use verbal de-escalation and reassurance..
  • Chemical restraint should accompany physical restraint.
  • Restraints can be physically dangerous, and frequent monitoring and reassessment with a plan to reduce restraint is a necessity.

Level 4: Resolution and Medication

Broadly, pharmacologic management of agitation includes the use of benzodiazepines, antipsychotics, or both. Side effects of these medications are common and include extrapyramidal symptoms [EPS], QTc prolongation, and neuroleptic malignant syndrome [NMS]. Benzodiazepines are less likely to cause EPS but may exacerbate delirium and sedation. They may lead to respiratory depression and should be used with caution in patients with decreased pulmonary reserve [8]. For dosing, see the algorithm for pharmacologic management in the Wilson Paper [8].

Mild agitation that is not responding well to verbal de-escalation can often be managed with a low dose of oral or sub-lingual medication if a patient assents. In severe agitation where safety of your team is compromised, consider parenteral route administration.

Consider the etiology:

In agitated delirium, it is important to determine if ethanol or benzodiazepine withdrawal is suspected. In non-withdrawal delirium, benzodiazepines can exacerbate confusion or induce delirium, and treatment with antipsychotics is preferable. Patients at risk for delirium may also be at increased risk of extrapyramidal symptoms (EPS) and an atypical antipsychotic with lower D2 receptor blockade (loxapine, olanzapine) can be used first. Notably, withdrawal from these substances is life threatening and must be managed with benzodiazepines.

If you suspect ethanol intoxication, avoid further CNS depression; an antipsychotic can be helpful. Haloperidol has a low anticholinergic burden and is considered relatively non-sedating. Patients may calm to a point where they are able to sleep.

In patients with a known history of psychosis, an antipsychotic is often helpful. Atypical agents, such as olanzapine, can be more sedating. Haldoperidol and risperidone can be used, but a benzodiazepine may need to be added to increase sedation and reduce EPS. Olanzapine and lorazepam cannot be given together intramuscularly due to an increased risk of hypotension.[9]

Rapid tranquillization is defined as – well, it’s basically what it sounds like. Different historical schemes have been described, with patients receiving over 100 milligrams of haloperidol in some settings. Standard practice is now to use a combination of antipsychotic and a benzodiazepine, with additional benzodiazepine later as needed.

This is where the “5 and 2” combination comes from, as haloperidol (5mg) and lorazepam (2mg) can be mixed in the same syringe. This can be used q30 minutes-2 hours to a maximum of 20mg of haloperidol per day. [10] The onset of action for IM lorazepam is 10 minutes, and haloperidol is 30-60 minutes, so physical restraints may be needed in the interim. See table 4 for pharmacokinetic properties of medications used in chemical restraints.

Table 4: Pharmacokinetics of antipsychotics [8, 10].

  Initial Dose (mg) Onset (min) TMax (hr) T ½ (hr) Repeat Max Dose (24 hr, mg)
PO:
Risperidone 2 1 20-24 2 6
Olanzapine 5-10 5 hours 6 30 2 20
Haloperidol 5 30-60 0.5-1 12-36 q15 min. 20
Loxapine 12.5-25 30 1-3 1-14 q1hr 150
Lorazepam (SL) 2 10 20-30 min. 12-15 2 12
IM:
Olanzapine 10 15-45 15-45 min. 30 q20 min. 30
Haloperidol 5 30-60 0.5-1 12-36 q15 min 20
Loxapine 12.5-25 15-30 5 8-23 q1hr 150
Lorazepam 2 10 20-30 min. 12-15 2 12
IV:
Haloperidol 2-5 30-60 STAT 12-36 4 10 (NB. QTc prolongation)

Violence is a growing concern in busy emergency departments. You can respond effectively by understanding basic approaches. A team debrief following each episode will aid the process of learning and improvement.

Summary:

Keep the following points in mind:

  • Agitation has a broad differential and may be a patient’s only means of communicating physical distress.
  • Recognizing agitation early and de-escalating the situation is easier and less distressing than dealing with a physically violent patient. Prevention is essential.
  • Do not hesitate to have security or another team member present during your assessment.
  • Match the level of response with the level of agitation. Use physical restraint if necessary to protect yourself and your team, but the least amount possible and with close monitoring reassessment. Chemical restraints should be used in conjunction with physical restraint.

For another take on the agitated patient, be sure to check out previous BoringEM posts on this topic: The Agitated Patient in the ED: Assessment & Mild Agitation and The Agitated Patient in the ED: Moderate & Severe Agitation.

References:

  1. Behnam, M. et al. (2011). Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine, May; 40(5):565-79. doi: 10.1016/j.jemermed.2009.11.007.
  2. Taylor, J. L. and Rew, L. (2011). A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing, 20: 1072–1085. doi: 10.1111/j.1365-2702.2010.03342.x
  3. Lofchy, J. S. (2010), Chapter 15: Emergency Assessment In: Goldbloom, D. S. (2010). Psychiatric Clinic Skills, Revised 1st Ed. Toronto, ON: Center for Addiction and Mental Health
  1. Richmond, J. S. Berlin, J. S. Fishkind, A. B. Holloman, G. H. Zeller, S. L. Wilson, M. P. Aly Rifai, M. Ng, A. T. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 17-25
  2. Fishkind, A. (2002). Calming agitation with words, not drugs: 10 commandments for safety. Current Psych. 2002;1(4). Available at: http://www. currentpsychiatry.com/pdf/0104/0104_Fishkind.pdf.
  3. Elgin, S. H. (1999) Language in Emergency Medicine: A Verbal Self-Defense Handbook. Bloomington, IN: XLibris Corporation
  4. Knox, D. K. Holloman, G. H. Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 35-40
  5. Wilson, M. P. Pepper, D. Currier, G. W. Holloman, G. H. Feifel, D. (2012). The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 26-34
  6. Zacher, J. L. Roche-Desilets, J. (2005) Hypotension secondary to the combination of intramuscular olanzapine and intramuscular lorazepam. Journal of Clinical Psychiatry, Vol. 66(12):1614-1615
  7. Marder, S. R. (2006). A review of agitation in mental illness: treatment guidelines and current therapies. Journal of Clinical Psychiatry, Vol. 67 Suppl. 10:13-21

Author information

Bruce Alex Fage
Bruce Alex Fage
Bruce is a resident at the University of Toronto's Psychiatry program. He is a graduate of Queen's University (#qmed14). He is also involved in the www.psychable.ca project, which aims to bring #FOAMed to the Psychiatry world.

The post Violence and Agitation in the Emergency Department appeared first on BoringEM and was written by Bruce Alex Fage.