MEDICAL EVALUATION AND TRIAGE OF THE AGITATED PATIENT

Key Highlights

• Various assessment scales available to determine the patient’s level of agitation¹
• Appropriate algorithms for triage and evaluation of an agitated patient in both nonmedical and medical settings¹
• Differentiation between medical and nonmedical causes of agitation for appropriate, precise, and timely treatment approaches¹

PSYCHIATRIC EVALUATION OF THE AGITATED PATIENT

Key Highlights

• Initial psychiatric assessment of agitated patients is challenging and usually cannot be completed until the patient is calm enough to participate²
• Initial evaluation aims to find the cause of the agitation through visual observation and collateral information²
• There is an algorithm for psychiatric assessment that provides a stepwise approach to evaluation²
• The goal of emergency assessment of psychiatric patients is not necessarily to obtain a diagnosis but to intervene and calm the patient²
• Once the patient is calmed, a more extensive psychiatric assessment can be completed²

VERBAL DE-ESCALATION OF THE AGITATED PATIENT

Key Highlights

• Verbal de-escalation techniques can decrease agitation and reduce the potential for associated violence, while empowering the patient to stay in control³
• The 4 main objectives when treating an agitated patient are to ensure the safety of the patient, staff, and others in the area, to help the patient manage his/her emotions and regain control, to avoid the use of restraint when at all possible, and to avoid coercive interventions that escalate agitation³
• There are 10 established domains of de-escalation that include but are not limited to respecting personal space, not being provocative, establishing verbal contact, being concise, setting clear limits, and offering choices and optimism³

THE PSYCHOPHARMACOLOGY OF AGITATION

Key Highlights

• Using medication as a restraint (ie, to restrict movement) should be discouraged⁴
• Verbal de-escalation and environmental stimulation should be attempted first⁴
• The goal of medication should be to calm the patient, not sedate⁴
• Patient involvement in the selection of type and route of medication is encouraged⁴
• If the patient is cooperative, oral medications should be offered over intramuscular injections⁴

USE AND AVOIDANCE OF SECLUSION AND RESTRAINT

Key Highlights

• Seclusion and restraint can cause adverse physical and psychological effects on staff and patients⁵
• Unless the patient is actively violent, verbal de-escalation should be tried first to encourage patient cooperation⁵
• Seclusion or restraint may be used only when less restrictive interventions have been determined to be ineffective⁵
• Seclusion or restraint may only be imposed to ensure the immediate physical safety of patients or staff⁵