Prevention and Management of Agitationin Emergency Departments
Released May 2021

Introduction
Agitation in patients in emergency departments (EDs) is becoming
more prevalent with 1.7 million episodes annually in the UnitedStates (Holloman, 2012). While the extent of aggression associatedwith agitation has not been clearly established, some patients who
are agitated are at risk of becoming aggressive and violent, andcan cause physical and psychological harm to themselves, other
patients and staff (Richmond, 2012).
It’s important to note that agitation is a symptom, whether ofmental illness, substance misuse, past trauma, or something else.
Properly assessing agitation and providing supports to people
who are experiencing agitation does prevent some aggressive
incidents. Evidence shows that among risk factors for incidents ofviolence in emergency department is inadequate or nonex­istent
training on the management of assaultive behaviors, understaffing,
and working alone (Solorzano Martinez, 2016).
Additionally, the ED environment itself can increase agitation: A
2020 narrative literature review found that between 46% and 89%of people who use mental health services have been exposed topast traumatic events and the ED environment can trigger fears
or traumatic memories (Molloy, 2020).

“Minnesota health systems
have found that collaborating to improve safety
makes infinitely more sensethan competing on patientor employee safety metrics.
In that spirit, ICSI fostered
the collaborative effort that
resulted in this ED agitation
management package,
which can promote safety
for all in one of the highest
risk hospital departments.”— J ESSICA MALONE
MN, RN, PHN
Clinical Care Improvement
Manager Psychiatry
Service Line,
Hennepin Healthcare

Setting up processes to support people experiencing agitation not only is better patient care, it is criticalin caring for staff. Being able to assess and intervene for people experiencing agitation also aids staff inidentifying when people are at risk of aggression. A systematic review on workplace violence in theemergency department found that emergency department workers are exposed to significant rates ofphysical and verbal abuse. It also found that under-reporting of workplace violence in the emergency
department to be common which contributes to the difficulty in accurately tracking violence (Taylor, 2011).
Emergency departments and inpatient psychiatric units have the highest rate of violent incidents comparedto other health care settings (Joint Commission, 2018).
Increased incidents of violence lead to staff burnout and low morale and subsequently higher turnoverrate (Joint Commission, 2018). In addition to staff, other patients are also at risk for being victimized if
agitation and aggressive behaviors are not properly assessed and managed.
Objective
Our goal for these recommendations is to shift the current thinking and practices around addressing
agitation from a reactive to a proactive response: preventing agitation or escalating agitation fromoccurring and providing a safe and therapeutic environment for all patients. This guide is intended tohelp organizations develop policy and procedures around agitation and violence prevention.
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Prevention and Management of Agitation in the ED

In the absence of high-quality evidence, this group seeks to provide practical guidance to ED
providers. Implementation of these practices may vary, depending on patient populations and ED
resources. We have provided questions throughout to help leaders discover possible areas for
systems improvement.
Scope:
This document focuses on the adult population (18 years of age and older) who present in the Emergency
Department. For populations younger than 18 years of age, refer to Project BETA which has publishedrecommendations for Best Practices for Evaluation and Treatment of Agitated Children and Adolescents(BETA) in the Emergency Department (Gerson, 2019).
Literature:
It is important to note that literature on agitation in the ED, particularly regarding interventions, is limited.
The following document is based on expert work group consensus as well as that of Project BETA, awork group convened by the American Association of Emergency Psychiatrists. Several organizations in
the working group have applied BETA work in their EDs with success. We have referenced the Project
BETA papers throughout this paper (papers are available for free download at the link provided). Seereferences sections for full citations.

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Prevention and Management of Agitation in the ED

Reactive to Proactive Response Framework
Initial Assessment
Warm Handoffs
Assessing for Agitation
Risk of Agitation
Risk of Violence

Emergency Department Management

GREEN ZONEYELLOW ZONE

RED ZONEPrevention for
Non-Agitated Person

Prevention of Escalation
for Agitated Person

Management of
Escalated Agitation• Engagement• Environment• Safety Precautions for
At Risk Patients• Monitoring for Agitation• Home Medications(patient is agitated, can betreated by care team)(agitation is escalating,additional resources are needed)• Safety Precautions• Safety Precautions• Assess and Manage
Underlying Etiology• Assess and Manage
Underlying Etiology• Verbal and Non-Verbal
Escalation• Verbal and Non-Verbal
Escalation• Pharmacologic Intervention
as Needed• Pharmacologic Intervention• Restraints

Disposition
Appropriate Level of Care
Warm Handoffs
Documentation

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Prevention and Management of Agitation in the ED

Recommendations
Note: Literature on agitation in the ED, particularly regarding interventions, is limited. The following
document is based on expert work group consensus as well as that of Project BETA, a work groupconvened by the American Association of Emergency Psychiatrists.

Initial Assessment
1. Warm Handoffs from Law Enforcement/First Responders	Note: There was no literature found to support guidance on this topic. The expert work groupconsensus is based on the existing practices and expert opinion and includes the following:		 •	A “heads up” from law enforcement/ambulance prior to arrival to ED. This will give time for
the ED staff to prepare for an arrival of a patient and provide an understanding on the levelof care and resources needed upon arrival. This could potentially help reduce delays inrooming and getting patients to appropriate level of care.
		 •	This “heads up” should include thorough collateral information and documentation of events
leading to presentation including understanding/knowledge of persons close to the patientwhich may be helpful during the assessment to disposition process.
		 •	Suggested key questions to include in the “heads up” for patients in psychiatric or substanceabuse distress arriving to the ED:				 °	What was the reason for the call and who made it?
				 °	Any suicidal concerns or threats to others?

				 °	Risk for overdose?
				 °	Other intoxicants/substance abuse?

				 °	Was patient cooperative and any medication needed for sedation/anxiolysis?
				 °	Had to utilize restraints?

				 °	Has patient been placed on hold?
				 °	Any other medical complaints, reported trauma or concerns thereof?

				 °	Known psychiatric history?
				 °	Where was patient picked up and what is home living situation?

				 °	
Any witnesses for potential collateral contact information?

QI:	How do our staff and law enforcement/first responders work together
to support patients’ care transitions?

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Prevention and Management of Agitation in the ED

2. Assessing for Agitation/Risk of Agitation on Arrival	On arrival to the ED, it is useful to evaluate the patient todetermine if they are: 1) currently agitated, 2) at risk for agitation
and/or 3) at risk for violent behavior. There are tools that may
be used to assess current state of agitation or risk of violencein the ED. It is important to note that assessment tools canhelp, but should not be used in place of clinical judgement.
Summary of Agitation Assessment Tools

Project BETA andAssessment
The Project BETA consensus
statement does not endorsea specific tool; however, it
finds the Behavioral Activity
Rating Scale (BARS) easy to
use reliably by both medicallytrained providers and those
who are not medically trained(Nordstrom, 2012).

		 • Behavioral Activity Rating Scale (BARS) is a scale
for measuring behavioral activity in acutely agitatedpatients. It is validated for measurement of behavioral
activity in acutely agitated patients with psychosis(Swift, 2002). The initial BARS score is based not only
on the patient’s presentation, but also on his behavior
before arrival to the ED, hence a reliable report from transport, where applicable, is beneficial.
Any score other than a 4 should trigger an evaluation by a clinician and establish the urgencyof that evaluation (Nordstrom, 2012; Richmond, 2012). The following link from Project BETA
paper (Nordstrom, 2012) provides BARS scoring table and algorithm for management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298208/
		 • OASS (Overt Agitation Severity Scale) is validated in young adult psychiatric inpatientpatients (Kopecky, 1998).
		 • OASS (Overt Aggression Severity Scale) measures aggressive behaviors in adults andchildren. On the Overt Aggression Scale (OAS), aggression is divided into four categories:
verbal aggression, physical aggression against objects, physical aggression against self,
and physical aggression against others. In addition, specific interventions related to eachaggressive event can be recorded on the OAS (Silver, 1991; Yudofsky, 1986). The full scale isavailable in Silver & Yudofsky, 1991.
Assessing for Risk of Violence in ED	Evidence shows association of the following patient-related risk factors with incidents of violencein emergency department: 1) male patient, 2) younger age, 3) mental health patients who are nottaking their medications, 4) patients brought in by police, or brought in by ambulance, 5) patients
who presented to the ED involuntarily and had a criminal history (Cabilan, 2019).
	Additional factors for risk of violence toward staff include: environmental factors such as poor
security, delays in service, and work­ing closely with potentially dangerous individuals; and staff
factors such as inadequate or nonex­istent training on the management of assaultive behaviors,
understaffing, and working alone (Solorzano Martinez, 2016).
Summary of Risk of Violence Assessment Tools
		 • Brøset Violence Checklist (BVC) uses six common behaviors (confusion, irritability,
boisterousness, verbal and physical threats, and attacking objects) to predict an acute episodeof violence in hospitalized psychiatric patients. The scoring levels are: Zero suggests that risk ofviolence in the next 24 h is low; 1–2 corresponds to moderate risk; and a score of ≥3 is high risk

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Prevention and Management of Agitation in the EDof violence. A study of 109 patients in inpatient psychiatric units found BVC to predict violence
within the next 24-hour period with moderate sensitivity and good specificity (Almvik, 2000).
A recent systematic review further confirmed this finding (Cabilan, 2019). This tool is copyrighted
and can be requested at: https://www.frenzs.org/bvc-broset-violence-checklist/		 • Violence/Aggression Assessment Checklist (VACC) – is an adaptation of BVC specificallyfor ED. It assists in predicting imminent violent behavior within the next 24 hours by assessing
for six behaviors: confused, irritable, boisterous, physically threatening, verbally threatening,
attacking objects. This tool is available at: https://www.theroyal.ca/sites/default/files/2019-08/
Violence_Aggression_Assessment_Checklist.pdf
		 • MIAHTAPS is a violence risk assessment tool developed by HealthPartners Regions Hospital.
It assesses for seven indicators of behaviors and past history: M-altered mental status, I-irritable,
A-agitated, H-history of violence, Threatening verbally, Attacking, throwing objects, PS-pacing
and/or staring. It combines information from Broset, BARS and STAMP. The tool is available
upon request from HealthPartners – Regions Hospital in St. Paul, MN.
		 • Violence Risk Screen Decision Support in Triage (VRSDSiT) – developed in Australia. An ED
tool for nursing staff to use at triage. It starts with a question “At risk of violence/or aggression?”
which prompts nurse to determine presence of risk factors such as involvement in assault,
intoxication, acute mental health symptoms, brought in by police, history of violence and behavioral
cues (i.e., uncooperative, hostile, intrusive or making verbal or physical threats). If the answer
is yes, the patient is flagged as at risk for violence. This tool has moderate sensitivity and good
specificity (Cabilan, 2019). In the tool dissertation report, the triage nurse used clinical judgement
to determine if there was risk for violence. This process was found to be feasible, acceptable
to clinical staff, integrated into current triage processes, and reflected the public’s expectationsof care. Communication of risk was facilitated using the existing clinical information system
and normal work flow within the ED. Overall, there was a reduction in time staff engaged in
responding to aggression; access to care was unchanged. However, there was an increase in theuse of coercive practices following implementation of this risk screening process (Daniel, 2015).
			Reference: Daniel C. An evaluation of violence risk screening at triage in one Australianemergency department (Dissertation). Melbourne: The University of Melbourne, 2015.
		 • STAMP assessment tool provides indicators for violent behavior using five observable behaviors
that indicate danger to others. STAMP mnemonic (Staring and eye contact, Tone and volume
of voice, Anxiety, Mumbling, and Pacing). While a case study identified these observablebehaviors to indicate a potential for violence at presentation at an emergency department (Luck,
2007), a recent scoping review found no specificity, sensitivity or predictive value of this tool
(Cabilan, 2019). A variation of this tool STAMP – EDAR (Staring and eye contact, Tone and volume
of voice, Anxiety, Mumbling, and Pacing - Emotions, Disease Process, Assertive/non-Assertive,
Resources) had the same finding in the review (Cabilan, 2019).
			 The tool is available in Luck 2007 article.

QI:	What is our process for assessing agitation, risk of agitation, and riskof violence in the ED?

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Prevention and Management of Agitation in the ED

ED Management
Green Zone (Prevention for Non-Agitated Patient)
1. Engagement
	A 2020 narrative literature review found that between 46% and 89% of people who use mental healthservices have been exposed to past traumatic events and the ED environment can trigger fears ortraumatic memories (Molloy, 2020). Applying the principles of trauma-informed care can potentiallyminimize this experience in these patients while in ED (Molloy, 2020).
	Trauma-informed care and cultural considerations are important parts of patient care. It is important that
staff have training in non-violent crisis intervention and early recognition/de-escalation of agitationthat consider patient cultural preferences and historical and present traumas that may guide approachto care decision-making. There are no specific tools related to trauma-informed care and agitation in
the ED. The following resource may be helpful: Trauma Informed Care – Implementation Resource at
https://www.traumainformedcare.chcs.org/

QI:	How might we better engage and support patients in the ED?
Do we effectively use the trauma-informed care frameworks?
Are there common trauma that our patients may have experienced
that we should better understand? (Migrants from war zones, racism…).

2. Environment	When possible, the least restrictive environment is preferable. Consider having food and beverageavailable, particularly for patients with extended stays.
	An alternative to the stressful ED environment is EmPATH and other types of observational units,
designed for patients with behavioral health needs. It is an area separate but adjoined to the regular
ED where patients can be assessed and treated by behavioral health professionals in an environmentthat is more calming.
	There are conflicting thoughts about posting signs about agitation/violence. While outlining unacceptablebehaviors may help, there are also concerns that it could encourage that behavior in patients who areseeking interaction with law enforcement.
	In the UK, signage about the process and time expectations within EDs have been helpful in decreasing
agitation and violence (Griffiths, 2013).

QI:
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What can we do differently to make our environment both safe and therapeutic?

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Prevention and Management of Agitation in the ED

3. Safety Precautions for At Risk Patients	Although non-agitated patients do not pose an immediate threat, it may be prudent to consider safety
precautions for patients with a history of agitation or other symptoms/behaviors that concern staff. Such
precautions may include separate rooming, scrubs, and/or a sitter. Systems differ in the use of theseprecautions routinely or a case-by-case basis. Both the safety of the patient, the safety of other patients,
and the safety of staff all need to be considered when deciding what precautions are warranted.
	It is important to consider any negative impact these precautions may have on the patient andwhether they may provoke agitation.

QI:

	What routine safety precautions have been taken for non-agitated patients
who may be at higher risk of agitation?

4. Monitoring for Agitation
	Patients should be monitored throughout their ED stay for new or changing agitation. This can bedone clinically and/or with the aid of a tool such as BARS.

QI:

How do we monitor for agitation during the ED stay?

5. Home Medications
	Delay or omittance of a patient’s regular medications may lead to agitation. It is the consensus of
this work group that wherever possible, giving home medications (in particular, those related tobehavioral health) should be considered by the treatment team while the patient is in the ED.

QI:	How often are home medications delayed or omitted, particularly for behavioral
health patients? What policies are in place regarding home medications?

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Prevention and Management of Agitation in the ED

Yellow Zone (Prevention of Escalation in Agitated Patient)
1. Safety Precautions
	For the agitated patient, safety precautions are especially important. This involves considering thesafety of the patient, other patients, and staff.
Patient considerations:	Decide whether the patient should be changed into hospital scrubs/clothes and whether a sitter isneeded. Refer to organizational policies and regulatory requirements when deciding on this.
Physical environment considerations: (Stowell, 2016)		 • Easily accessible alarm systems		 •	Doors that open outward, cannot be locked from inside, allow easy accessfrom the outside in event of emergency		 • Barrier-resistant doors, which contain a small compact door within the door		 • Location close to staff areas		 • Unobstructed viewing window

QI:	What additional safety precautions are taken for agitated patients? Are
there changes you need to make in the physical environment that would
increase safety while considering trauma informed care principles?

2. Assess and Manage Underlying Etiology
	The patient should be assessed for underlying medical and psychiatric conditions that may cause orcontribute to the agitation. Labs and imaging should be based on clinical judgment. The following isdifferential diagnosis:
Differential Diagnosis Underlying Agitation (Nordstrom, 2012)9

Medical

PsychiatricIntoxication• Head trauma• Encephalitis, meningitis, or other infection• Encephalopathy (particularly from liver or
renal failure)• Exposure to environmental toxins• Metabolic derangement (e.g., hyponatremia,
hypocalcemia, hypoglycemia)• Hypoxia• Thyroid disease• Seizure (postictal)• Toxic levels of medications (e.g., psychiatricor antiseizure)•P sychotic disorders• Mania•A gitated depression•A nxiety disorders• Alcohol• Club or recreational
drugs (cocaine,
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Prevention and Management of Agitation in the ED		 • Labs and imaging should be based on individual patient presentation. See Medical
Clearance Evaluation for more information.
		 • Information from both medical and psychiatric evaluation should be thoroughly documented.
		 •	
To ensure legal compliance, EDs should be aware of latest laws in their area around involuntarytreatment and commitment, salutatory reporting requirements based on information obtained
during assessment, and duty to warn others of the risk.

QI:	What routine labs or other evaluation protocols are there for a patientpresenting with agitation? Do these need updating? Are they individualized
per patient presentation?

3. Verbal and Non-Verbal De-Escalation
	Verbal de-escalation is a method to calm the agitated patient and gain patient’s cooperation in theevaluation and treatment of the agitation and reduce involuntary medication, seclusion, and physicalrestraints. Non-verbal de-escalation includes interpersonal non-verbals and the physical environment.
	The following are Project BETA guidelines on preparing to conduct verbal de-escalation (Richmond, 2012).
1. Physical Space Should Be Designed for Safety		Main points:		 •	Use moveable furniture to help create a safe environment. Emergency departments may
also use stationary furniture, so that the patient cannot use the objects as weapons.
However, Project BETA also cautions that latter may create a false sense of security.
		 •	Avoid extremes in sound, wall color, and temperature of the environment as these canexacerbate sensory stimulation.
		 •	Ensure adequate exits.
		 •	Remove or secure objects (pens, sharp objects, table lamps, etc.) that may cause injuries
to others. Monitor objects that cannot be removed.
2. Staff Should Be Appropriate for the Job		Main points:		 •	Clinicians must be good at multitasking and be able to respond quickly to changing patientpriorities.
		 •	Temperament for working with patients who are agitated.
		 •	Self-awareness such that staff members are able to recognize their own negative reactions
or behaviors toward agitated patient’s behaviors. Staff should be able to recognize when
they are engaging into behaviors (e.g., arguing, tendency to retaliate, or become defensive)that can only worsen their interaction with the patient.
		 •	Ability to seek additional help when they are no longer able to deal with an agitated patient.
		 •	Any provider can learn de-escalation skills. The essential skillset includes a helpful attitude,
starting with positive regard for the patient and the capacity for empathy. Clinicians need toalso be able to differentiate when cognitive issues, intellectual disability, delirium, psychosis,
intoxication or personality disorder affect patient’s ability to conform to instructions.
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3. Staff Must Be Adequately Trained		
Main points:		 •	Practice by role playing. Also consider practicing skills with non-agitated patients who areunable to follow directions because of cognitive issues or other conditions.
		 •	Use verbal loop with patients by mirroring/reflecting what they are saying. Persistence iskey. It is important to not give up after a few tries of verbal loops. If patient is not responding
to de-escalation efforts, the clinicians should persist in repeating it, especially in situations
where patient is not showing signs of becoming violent.
		 •	Successful de-escalation can be successfully done in 5-10 minutes, depending on patientcomplications.
		 •	Some patients may not be able to engage in de-escalation efforts due to delirium or otherconditions.
4. An Adequate Number of Trained Staff Must Be Available:		
Main point:		 •	The de-escalation team should consist of 4 to 6 team members made up of nurses,
clinicians, technicians, and police and security officers, if available.
5. Use Objective Scales to Assess Agitation
		Main points:		 •	Use an objective scale such as BARS to assess for level of agitation.
		 •	Base the initial BARS score not only on the patient’s presentation, but also on the behavior
before arrival at the emergency facility. Any score other than a 4 should trigger an evaluation
by a clinician and the urgency established.
6. Clinicians Should Self-Monitor and Feel Safe When Approaching the Patient		
Main point:		 •	Much of the clinician/patient communication occurs via body language, especially tone ofvoice. It is important for clinician to remain calm in their interaction with agitated patient inorder to be effective.
7. 10 Domains of De-Escalation Exist that Help Clinicians’ Care of Agitated Patients				 i. Domain I: Respect Personal Space				 ii. Domain II: Do Not Be Provocative				 iii. Domain III: Establish Verbal Contact				 iv. Domain IV: Be Concise				 v. Domain V: Identify Wants and Feelings				 vi. Domain VI: Listen Closely to What the Patient Is Saying				 vii. Domain VII: Agree or Agree to Disagree				 viii. Domain VIII: Lay Down the Law and Set Clear Limits				 ix. Domain IX: Offer Choices and Optimism				 x. Domain X: Debrief the Patient and Staff		Detailed recommendations for each of the domains are explained in Richmond et al (2012).

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Prevention and Management of Agitation in the ED

Additional De-Escalation Tips Found useful and contributed by Members of the ICSI Working Group		 •	Keep body language alert, but relaxed. Don’t fold your arms in front of your chest or hands inyour pockets (this makes it unsafe if someone strikes as you would have decreased reactiontime). Have hands positioned in front of you, with palms upwards (this shows the other person
you are not hiding anything in your hands, as well as keeps your hands and arms ready todeflect any physical blows).
		 •	Avoid movements that could be perceived as threatening (e.g. hands at the hip).
		 •	Angle lower body/feet 45 degrees from the person. This allows you to protect your “sensitive
areas” but also sets up your feet to swiftly move sideways if you need to deflect any physicalblows. This is also less intimidating than a completely forward stance.
		 •	Stay two arms lengths away; it gives space to the agitated patient and keeps your body safe
as well.
		 •	
Maintain a neutral face, do your best to appear calm and level headed. Your increased anxiety
can increase the anxiety in the patient. Avoid facial expressions and overreacting.
		 •	If safe, maintain eye level positioning. If the patient is sitting, you sit. If the patient is standing,you stand.
		 •	
Limit overall touching. Agitated patients can view touching as hostile, even if the touch is meant
to calm someone (i.e., limit touching someone’s shoulder when agitated even though this is anatural reaction we make to comfort someone)		 •	Have awareness of positioning in a room to avoid feeling trapped/backed into a corner andproviding a sense of safe exit (staff and patient).
		 •	You can acknowledge and emphasize with a patient’s feelings but not excuse the behaviors(i.e., I understand why you would be upset, but it is not okay to threaten me).
		 •	Don’t argue with an escalated patient. If their tone is heightened, a patient is less likely torespond to logic or argument.

QI:	How are staff trained in verbal and non-verbal de-escalation? Do staff feel itis sufficient? Are there cultural or other norms in the population(s) you servethat need to be considered in your de-escalation plans and training?

4. Pharmacologic Interventions
	Nonpharmacologic approaches, such as verbal de-escalation and reducing environmental
stimulation (quiet room, low lighting), should be attempted, if possible, before medications areadministered.
	Patients should be engaged in the process of determining the mode of medication delivery (oralvs. intramuscular). If the patient is able to cooperate and there is no contraindication to use, oral
medications are preferred over intramuscular ones.

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Prevention and Management of Agitation in the ED	This work group endorses Project BETA recommendations on medication use (Wilson, 2012),
however, the implementation of these may be facility and situation dependent. Therefore, the workgroup believes that the individual organizations should have the flexibility in how they implement
these recommendations.
	Please see Project BETA Recommendations (Wilson, 2012) for full discussion on medicationuse, including medication table and algorithm for pharmacologic management. The document
provides treatment protocols for agitation associated with delirium, agitation due to intoxication,
agitation with psychosis in patient with known psychiatric disorder, and undifferentiated agitation.
	Since the Project BETA 2012 guideline, a 2016 systematic review by Korczak et al (2016) was publishedlooking at medication used to sedate agitation in patients in the emergency department. It included
seven studies with 1,135 patients; reason for patient agitation was not reported (Korczak, 2016).
Conclusions:		 •	Need for repeat sedation:				 °	Four studies were included in the analysis comparing the need for repeat sedation
between antipsychotics and benzodiazepines. Antipsychotics were found to be more
effective, as fewer repeat doses needed to be given.
				 °	When benzodiazepines were compared with combination therapy (antipsychotics andbenzodiazepines), two studies showed that combination therapy requires less repeat
sedation than when benzodiazepines were given alone.
				 °	Antipsychotics were compared with combination therapy in only one study and notanalyzed further.
		 •	Adverse events: Benzodiazepines were more likely to lead to adverse events, primarily
involving the respiratory system.

QI:	What are the organizational policies and procedures around giving
medication for agitated patients? Do these need to be updated to reflectcurrent evidence? Do these encourage patient choice, where possible?

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Prevention and Management of Agitation in the ED

Red Zone (Management of Escalated Agitation)
1. Team Response & Safety Precautions
	For a patient with escalating agitation, aggression or violent behavior, additional staff may be needed.
Often this may happen in the form of a “code,” where additional staff from the ED or elsewhere in thehospital may assist. Safety precautions, as outlined above for agitated patients, should be put in place
if not already done so.
Project BETA guidance: (Richmond, 2012)		 •	
Important to differentiate between different types of aggression (instrumental or non-emotional,
using threat of violence to get what one wants, fear-driven, irritable which can be either
chronically angry patients or patients who have had boundaries violated) and apply appropriate
de-escalation interventions based on type. Detailed explanation of aggression types andinterventions can be found in Richmond et al (2012).
		 •	
Patients that do not respond to de-escalation interventions may need to be restrained, if escalate
to violence.

QI:	How does our behavioral health ‘code’ team operate? What works well andwhat needs improvement? Are all on the team trained in assessing aggression
types and using appropriate techniques? How are team members quickly
briefed before engaging with the patient?

2. Assess and Manage Underlying Etiology	If patient presents in the red zone with escalating agitation and threat of aggression, then assessmentand management of underlying etiology should be done. See details in yellow zone. This assessmentand management may warrant repeating if patient’s agitation is worsening.
3. Verbal and Non-Verbal De-Escalation
See details in yellow zone on guidance for verbal and non-verbal de-escalation.
4. Seclusions and Restraints
	These interventions should be used as a last resort. There are multiple potential implications for bothpatients and staff including, increased likelihood of patient disengagement and lessened success of
forming a collaborative relationship, increased incidence of injury (physical and psychological) to bothpatients and staff, psychological distress, safety and adverse events of medications, and financial andlegal consequences for health care organizations (Knox, 2012).
	In general, use of forced restraints and seclusions is regulated by the Centers for Medicare andMedicaid Services (CMS) and health care organizations are legally mandated to follow and incorporate
CMS guidelines into their policies and procedures. These policies should consider patient rights andlegal implications of use of restraints and seclusions. The regulations also include requirements forstaff training on verbal de-escalation, management of aggressive behavior and types of restraints
that may be used or how to apply them (Knox, 2012). Organizations should be up to date on the latest
CMS regulations and state and national laws and adjust their policies and procedures accordingly.
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Prevention and Management of Agitation in the ED

The goal for every organization should be to reduce the use of forced seclusions and restraints.
According to Project BETA, the following approaches to achieve this goal may be used: (Knox, 2012)
Note: Italicized copy is directly from Project BETA.
		 •	Change in organization culture where restraint is viewed as a treatment failure		 •	Implementation of an administrative quality management review process aimed at
improving outcomes in managing aggressive behavior		 •	Regular staff feedback		 •	Early identification and intervention using de-escalation techniques, and		 •	The use of protocols or aggressive management algorithms to guide clinical interventions.
CMS has adopted the following definitions for restraints and seclusions: (Knox, 2012)		 •	Seclusion is the involuntary confinement of a patient alone in a room or area from which
the patient is physically prevented from leaving. Seclusion may be used only for the
management of violent or self-destructive behavior.
		 •	A restraint is any manual method, physical or mechanical device, material, or equipmentthat immobilizes or reduces the ability of a patient to move his or her arms, legs, body, orhead freely.
		 •	A drug is considered a restraint when it is used as a restriction to manage the patient’s
behavior or restrict the patient’s freedom of movement and is not a standard treatment
or dosage for the patient’s condition.
		 •	Seclusion and restraint must be discontinued at the earliest possible time.
		 •	Within 1 hour of the seclusion or restraint, a patient must be evaluated face-to-face by aphysician or other licensed independent practitioner or by a registered nurse or physician
assistant who has met specified training requirements.
Specific to patient ‘s rights: (Knox, 2012)		 •	Seclusion or restraint may be used only when less restrictive interventions have been
determined to be ineffective to protect the patient, a staff member, or others from harm.
		 •	All patients have the right to be free from restraint or seclusion, of any form, imposed asa means of coercion, discipline, convenience, or retaliation by staff.
		 •	Restraint or seclusion may only be imposed to ensure the immediate physical safety ofthe patient, a staff member, or others.
Project BETA guidelines on the use of seclusions or restraints: (Knox, 2012)		 •	The least restrictive intervention should be chosen and the goal of treatment is to minimize
time in forced seclusion or restraint.
		 •	For patients who are not actively violent, start with verbal de-escalation. If medication isoffered, try to involve patients in decision making on medications.
		 •	If the patient is not a danger to others, seclusion should be considered. However, if thepatient would be a danger to himself while in seclusion, restraint is appropriate.
		 •	If the patient is an immediate danger to others, restraint is indicated.

15© ICSI 2021

Prevention and Management of Agitation in the ED		 •	If the restrained patient will engage in a reasonable dialog, verbal de-escalation efforts
should continue, including getting the patient’s input on medication. Either way, medication
should be administered to calm a patient who has been placed in restraints.
		 •	A quiet, unlocked seclusion room should be used if restraint is not indicated and the patientis willing to sit; if not, then forced seclusion is indicated.
		 •	Seclusion with decreased stimulation may help some patients regain control while others
may need a combination of ongoing verbal de-escalation and medications.
		 •	All patients in restraint or seclusion should be monitored to assess response to medicationand to prevent complications from these interventions.
		 •	When the patient has regained control, a more thorough evaluation can be done, followed
by further treatment planning and determining disposition.

Disposition
1.	Appropriate Level of Care
Considerations for moving patients to different levels of care:		 •	Determine which patients are appropriate for inpatient psychiatric admission vs. discharge
to the community. Refer to the MN Health Collaborative recommendations on Medical
Clearance and Suicide Prevention and Intervention in the ED on possible guidance.
		 • Group home patients – can they go back or do they need to move to a different care setting?
		 • Which patients may be safely discharged home?
		 •	EmPATH and other types of observational units – is it possible to hold patients there untila spot in the community becomes available?
		 • Be aware of all the resources in the community.
		 •	Continue to build partnerships with mental health and other community resources, wherethese are available.

QI:

	What are our three biggest challenges in disposition? What knowledge
or relationships do we need to address these challenges?

2. Hand-offs and Documentation
	Warm handoffs are critical for a patient with agitation. Standardized questions may help with intraand inter-organizational communication.

QI:

	What information is critical in a handoff? How can the patient’s behavior
during their time in the ED be helpfully summarized (e.g., What de-escalation
techniques were effective)? What needs to be documented in the chart?

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Prevention and Management of Agitation in the ED

References
Project BETA for Adults:
1.	Holloman GH Jr, Zeller SL. Overview of Project BETA: Best practices in Evaluation andTreatment of Agitation. West J Emerg Med. 2012 Feb;13(1):1-2. https://pubmed.ncbi.nlm.nih.
gov/22461914/
2.	Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, Anderson EL. Medical
Evaluation and Triage of the Agitated Patient: Consensus Statement of the American
Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. West J
Emerg Med. 2012 Feb;13(1):3-10. https://pubmed.ncbi.nlm.nih.gov/22461915/
3.	Stowell KR, Florence P, Harman HJ, Glick RL. Psychiatric Evaluation of the Agitated Patient:
Consensus Statement of the American Association for Emergency Psychiatry Pproject BETA
Psychiatric Evaluation Workgroup. West J Emerg Med. 2012 Feb;13(1):11-6. https://pubmed.ncbi.
nlm.nih.gov/22461916/
4.	Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng
AT. Verbal De-Escalation of the Agitated Patient: Consensus Statement of the American
Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg
Med. 2012 Feb;13(1):17-25. https://pubmed.ncbi.nlm.nih.gov/22461917/
5.	Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The Psychopharmacology ofAgitation: Consensus Statement of the American Association for Emergency Psychiatry Project
BETA Psychopharmacology Workgroup. West J Emerg Med. 2012 Feb;13(1):26-34. https://
pubmed.ncbi.nlm.nih.gov/22461918/
6. 	Knox DK, Holloman GH Jr. Use and Avoidance of Seclusion and Restraint: Consensus
Statement of the American Association for Emergency Psychiatry Project BETA Seclusion andRestraint Workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. https://pubmed.ncbi.nlm.nih.
gov/22461919/
Project BETA for Children and Adolescents:
Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation andTreatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus
Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019
Mar;20(2):409-418. https://pubmed.ncbi.nlm.nih.gov/30881565/ Epub 2019 Feb 19.
Other:
Almvik, R., Woods, P., & Rasmussen, K. The Brøset Violence Checklist: Sensitivity, specificity, andinterrater reliability. Journal of Interpersonal Violence, 2000 15(12), 1284–1296. https://psycnet.apa.
org/record/2000-12306-003.
Cabilan CJ, Johnston AN. Review article: Identifying occupational violence patient risk factors andrisk assessment tools in the emergency department: A scoping review. Emerg Med Australas. 2019
Oct;31(5):730-740. https://pubmed.ncbi.nlm.nih.gov/31368230/. Epub 2019 Jul 31.
Frueh BC, Knapp RG, Cusack KJ, et al. Patients’ reports of traumatic or harmful experiences within thepsychiatric setting. Psychiatr Serv. 2005;56:1123–1133. https://pubmed.ncbi.nlm.nih.gov/16148328/

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Gates DM, Ross CS, McQueen L. Violence against emergency department workers. J Emerg
Med.2006;31:331–337. https://pubmed.ncbi.nlm.nih.gov/16982376/
Griffiths, A. Signage system designed for hospitals reduces violence by 50 percent. dezeen. 2013
Dec. https://www.dezeen.com/2013/12/02/hospital-redesign-by-pearsonlloyd-reduces-violence-andaggression/
Joint Commission, The. Sentinel Event Alert. 2018 April. Issue 59.
Kopecky HJ, Kopecky CR, Yudofsky SC. Reliability and validity of the Overt Agitation Severity Scalein adult psychiatric inpatients. Psychiatr Q. Winter 1998;69(4):301-23. https://pubmed.ncbi.nlm.nih.
gov/9793109/
Korczak V, Kirby A, Gunja N. Chemical agents for the sedation of agitated patients in the ED: asystematic review. American Journal of Emergency Medicine 2016;34:2426-2431.
Lam LT. Aggression exposure and mental health among nurses. Aust e-J Adv Ment
Health.2002;1:89–100. https://www.tandfonline.com/doi/abs/10.5172/jamh.1.2.89
Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential forpatient violence in emergency departments. J Adv Nurs. 2007 Jul;59(1):11-9. https://pubmed.ncbi.nlm.
nih.gov/17543010/ Epub 2007 Jun 3.
Molloy L, Fields L, Trostian B, Kinghorn G. Trauma-informed care for people presenting to theemergency department with mental health issues. Emerg Nurse. 2020 Mar 10;28(2):30-35. doi:
10.7748/en.2020.e1990. Epub 2020 Feb 25.
Silver JM, Yudofsky SC. The Overt Aggression Scale: overview and guiding principles. J
Neuropsychiatry Clin Neurosci. Spring 1991;3(2):S22-9.
Solorzano Martinez AJ. Managing Workplace Violence With Evidence-Based Interventions: A
Literature Review. J Psychosoc Nurs Ment Health Serv. 2016 Sep 1;54(9):31-6. https://pubmed.ncbi.
nlm.nih.gov/27576226/
Stowell KR, Hughes NP, Rozel JS. Violence in the Emergency Department. Psychiatr Clin North Am.
2016 Dec;39(4):557-566. https://pubmed.ncbi.nlm.nih.gov/27836151/ Epub 2016 Sep 28.
Swift, RH., Harrigan, EP., et al. Validation of the Behavioural Activity Rating Scale (BARS): a novel
measure of activity in agitated patients. J Psychiatr Res. 2002 Mar-Apr;36(2):87-95. https://pubmed.
ncbi.nlm.nih.gov/11777497/
Woods, P., Almvik, R. The Broset Violence Checklist (BVC). Acta Psychiatr Scand Suppl.
2002;(412):103-5. https://pubmed.ncbi.nlm.nih.gov/12072138/
Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for theobjective rating of verbal and physical aggression. Am J Psychiatry. 1986 Jan;143(1):35-9. https://
pubmed.ncbi.nlm.nih.gov/3942284/

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Prevention and Management of Agitation in the ED

Contributing Members and Organizations
Allina Health
Eric Haug, MD
Suzanne Witterholt, MD
CentraCare HealthTravis Hodgins, MSN, RN
Larry Hook, MD
Seth Royce MSN, RN
Jon Schmitz, MDChildren’s Minnesota
Nicole Helland, LICSW
Joel Spalding, MD
Essentia Health
Laura Kitch, APRN, CNS
HealthPartners
Ryan Aga, MSN, BS, RN, CEN CPEN, PHN
Kurt Isenberger, MD
Christine Stanson, MD
Joe Uzpen, PA-C
Hennepin Healthcare
Morgan Faust
Jessica Malone, MN, RN, PHN

19

M Health Fairview
Eric Christianson, MD
Jennifer Dewald MPA, RN, BCEN, NEA-BC
Lew Zeidner, PhD
North Memorial HealthChristopher Palmer, MD
Park Nicollet Methodist Hospital
Eric Graff, MBA, BSN, RN
Joe Dolan, MD
Michael Knudsen, MD
Ridgeview Medical Center
Greg Peterson, MD
Sanford Health
Jay Coughenour
ICSI Staff
Jodie Dvorkin, MD, MPH
Senka Hadzic, MPH
Tani Hemmila, MS
Claire Neely, MD, FAAP

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