Mental illness and substance abuse emergencies now account for one in every eight emergency department (ED) visits. Unfortunately, many ED providers aren't confident managing patients who are tense, restless, uncooperative, and show other signs of agitation. This often to leads patients being sedated unnecessarily, which can delay recovery, increase the likelihood of admission, and prolong an already extended ED stay.
Perspectives recently sat down with Scott Zeller, MD, Vice President of Acute Psychiatry at Vituity, for his advice on treating agitated patients. Zeller has almost 30 years of experience educating healthcare providers and administrators on agitation. He’s also lead editor of the groundbreaking textbook, The Diagnosis and Management of Agitation (reviewed here). And he was instrumental in creating the American Association for Emergency Psychiatry’s Best Practices in the Evaluation and Treatment of Agitation.
In today's post, Zeller discusses how many EDs go wrong when treating agitated patients and how to respond more effectively through respectful de-escalation techniques. He also shows us how de-escalation benefits providers, EDs, and hospitals.
Perspectives: Can you tell us about how you became interested in treating agitation?
Dr. Zeller: Well, agitated patients are really the “bread and butter” of acute psychiatry. They’re involved in a substantial number of U.S. ED visits — about 1.7 million per year. That’s a staggering number.
EDs aren’t always well equipped to help this population. Agitated patients have trouble communicating their needs and can become physically and verbally aggressive toward ED staff.
They’re patients who are really sick and aren’t getting the help they need. That's why I became such an advocate for respectful de-escalation treatment. It works, but too often, it isn’t being utilized.
Perspectives: How are EDs typically treating these patients, and where are they going wrong?
Dr. Zeller: Unfortunately, we see a lot of inappropriate treatment, even at EDs with psych programs. ED visits among psychiatric patients are on the rise. But many providers still don’t know about agitation or how to treat it. Agitated patients are sometimes even looked at as bad people who deserve a harsh response.
Often, patients receive overly aggressive treatment like physical restraints or heavy sedation in an attempt to combat agitation symptoms. Unfortunately, once patients are heavily sedated, they end up unconscious, and can be unarousable and thus remain the ED for as long as 16–24 hours. This is unfortunate, because with appropriate treatment, they could have been substantially improved and possibly already discharged home in a much shorter time period. And for most cases, this heavy sedation doesn’t need to be used.
Agitated patients are typically not bad people, but good people who are struggling with a challenging illness. They should be treated with the same compassion and equal respect as patients with physical illness.
Perspectives: Are there other challenges when it comes to caring for these patients?
Dr. Zeller: Many EDs lack access to psychiatric consults and have limited disposition options for mental health cases. As a result, on a national basis, mental health and substance abuse patients in EDs wait an average of 8 to 34 hours for a psychiatric disposition, which is about three times longer than patients with physical illness.
Often, patients in a mental health crisis are already suffering, and long waits can exacerbate that distress, making their symptoms worse and possibly engendering agitation.
Perspectives: How are you helping providers appropriately and effectively treat agitated patients?
Dr. Zeller: It starts with building awareness of what agitation is: a real symptom of many mental health conditions.
When educating providers, I compare a patient who’s having an agitation episode to a patient who’s having a heart attack. You don’t get angry with them or blame them for having a heart attack. You help them. Most providers can relate to that.
I stress that like patients with physical illness, agitated patients want to get better. These people are suffering and need help, even if they don’t always act like they want it.
Perspectives: Who’s been helpful in creating this research? Who’ve you collaborated with?
Dr. Zeller: It’s definitely the patients. It’s been so eye-opening working with the Depression and Bipolar Support Alliance.
DBSA is an advocacy group made up of people who have histories of bipolar disorder or depression. Between acute episodes, people with this illness can function very well and provide insight into their experience. So they’re an invaluable resource, because they can really tell us as providers what’s working and what’s not working.
Perspectives: What’s the biggest challenge and frustration you hear from patients?
Dr. Zeller: They remember how they were treated. There’s a misconception that patients won’t remember what occurred during an agitation episode. But that’s not the case; they remember everything. Patients often say, “A lot of maltreatment could‘ve been avoided if someone would’ve just listened to me.”
Perspectives: How can agitation be treated more effectively and humanely?
Dr. Zeller: We want to provide the best care possible and want our patients to have a positive, supported experience. Treating a violent, agitated person with violence leads to more agitation and more violence. That’s not healthy for patients or ED staff.
Research suggests that verbal de-escalation can be very effective with this group. The goal is to get agitated patients calm without sedation or physical force.
Another benefit of de-escalation is that it doesn't prolong the patient's stay — and may very well even shorten it. That's good news for your typical ED that's struggling to improve throughput. In fact, patients who are placed in physical restraints in EDs stay an average of an additional 4.2 hours!
Perspectives: What are the key messages you use for de-escalation?
Dr. Zeller: Understand when someone is angry, they expect things to get worse. Surprise agitated patients with kindness to help them get better.
- Start by being respectful and understanding.
- Show you want to help, not jail them.
- Repeat yourself. Often patients need to hear you want to help many times before they can understand.
- Offer a quiet place for the patient to be alone to calm down. Offer to bring food or a drink.
- Respect the patient’s personal space.
- Identify the patient’s wants and feelings.
- Set expectations and offer choices for next steps.
Perspectives: Tell us a little about how you’re sharing these de-escalation techniques.
Dr. Zeller: We made a how-to training video on de-escalation with DBSA. The goal was and still is to actively deliver the video to every hospital in United States.
As it so happened, we were able to recruit an actor who has bipolar disorder. He'd previously been treated for agitation in the ED, and he did a great job reenacting his experience.
So far, we’ve had a ton of views! And last year, we were thrilled when the World Health Organization incorporated our video into their QualityRights training initiative. QualityRights seeks to align mental health services around the world with international human rights standards and best practices.
Perspective: What brings you satisfaction in your work?
Dr. Zeller: Knowing that this de-escalation treatment is effective and satisfying. And that we are caring for our patients in a kind, thoughtful manner.
De-escalation helps patients who really need help getting care to be healthy and safe. It also gives ED staff the techniques to provide the best care for their patients. When providers have the tools they need to help, they feel safer and more satisfied in their roles.
To learn more about how Vituity helps hospitals provide exceptional care to patients in mental health crisis, visit our Acute Psychiatry page.
Last updated Oct. 15, 2018.