The agitated patient: Steps to take, how to stay safe

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Applied Evidence

The agitated patient: Steps to take, how to stay safe

J Fam Pract. 2018 March;67(3):136-141,144-147

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References

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2. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers. 2016. Available at: https://www.osha.gov/Publications/osha3148.pdf. Accessed February 8, 2017.

3. Mortimer DS, Berg W. Agitation in patients recovering from traumatic brain injury: nursing management. J Neurosci Nurs. 2017;49:25-30.

4. Wilson MP, Nordstrom K, Vilke GM. The agitated patient in the emergency department. Curr Emerg Hosp Med Rep. 2015;3:188-194.

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6. Gaynes BN, Brown CL, Lux LJ, et al. Preventing and de-escalating aggressive behavior among adult psychiatric patients: a systematic review of the evidence. Psychiatr Serv. 2017;68:819-831.

7. Nordstrom K, Zun LS, Wilson MP, et al. 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;13:3-10.

8. Sands N. Mental health triage: towards a model for nursing practice. J Psychiatr Ment Health Nurs. 2007;14:243-249.

9. Sim MG, Wain T, Khong E. Aggressive behaviour - prevention and management in the general practice environment. Aust Fam Physician. 2011;40:866-872.

10. Swift RH, Harrigan EP, Cappelleri JC, et al. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36:87-95.

11. Ng J, Pan CX, Geube A, et al. Your postop patient is confused and agitated—next steps? J Fam Pract. 2015;64:361-366.

12. Vorderwülbecke F, Feistle M, Mehring M, et al. Aggression and violence against primary care physicians—a nationwide questionnaire survey. Dtsch Arztebl Int. 2015;112:159-165.

13. Bell HS. Curbside consultation—a potentially violent patient? Am Fam Physician. 2000;61:2237-2238.

14. Taylor H. Patient violence against clinicians: managing the risk. Innov Clin Neurosci. 2013;10:40-42.

15. Munsey C. How to stay safe in practice. APA Monitor. 2008;39:36.

16. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Am J Psychiatry. 2016;173:543-546.

17. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Family Medicine. Revised July 1, 2017. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/120_family_medicine_2017-07-01.pdf . Accessed October 30, 2017.

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Long- and short-term care facilities

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include:⁴

Have an established plan for the management of agitated patients.
Identify signs of agitation early, and complete an agitation rating scale.
Attempt verbal de-escalation before using medication whenever possible.
Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³