Article, Cardiology

Use of sedatives and restraints for treatment of agitation in the emergency department

References

Hatzaras IS, Bible JE, Koullias GJ, Tranquilli M, Singh M, Elefteriades JA. Role of exer- tion or emotion as inciting events for acute aortic dissection. Am J Cardiol 2007; 100:1470-2.
  • Inamasu J, Miyatake S, Yagi T, Noma S. Acute coronary syndromes occurring while
  • driving: frequency and patient characteristics. Environ Health Prev Med 2017;22 (1):82.

    Inamasu J, Miyatake S, Yagi T, Noma S. Resuscitation outcomes of cardiac arrest pa- tients who caused witnessed non-fatal Road traffic accidents while driving. Resuscita- tion 2017;119:e15-6.
  • Kojima S, Sumiyoshi M, Nakata Y, Daida H. Triggers and circadian distribution of the onset of acute aortic dissection. Circ J 2002;66:232-5.
  • Yoshizaki T, Kimura N, Hirano T, Yamaguchi A, Adachi H. Acute aortic dissection oc- curring “behind the wheel”, report of 11 cases. Ann Vasc Dis 2016;9:205-8.
  • Use of sedatives and restraints for treatment of agitation in the emergency department

    Agitation is a growing and pervasive problem in emergency depart- ments (EDs) across the United States, with an estimated 1.7 million events occurring annually in emergency settings [1,2]. Treatment rou- tinely involves the use of coercive measures consisting of physical re- straints and sedatives, but they can lead to significant harm for patients. Cited adverse events have included lasting psychological dis- tress, respiratory depression, Physical trauma, and asphyxiation lead- ing to cardiac arrest [3-5]. Efforts to reduce threats to patient safety have recently led to calls for utilization of evidence-based algorithms to help clinicians determine when coercive measures are most appro- priate [6].

    Despite these recommendations, there remains a lack of standardiza- tion for initiation of coercive measures in the ED [7,8]. In part, this vari- ation in practice has been attributed to limited existing knowledge regarding agitation characteristics specific to the emergency setting [9]. Unlike the inpatient or psychiatric units, the ED faces higher acuity of agitation with more varied and complex Patient presentations that may lead to aggression and violence [10,11]. Currently, characterization of ED agitation events are mostly derived from health worker surveys in the context of addressing workplace violence [12,13]. In contrast, we sought to examine the use of sedatives and restraints when treating ag- itation in the ED through prospective observations of patient encoun- ters. This will aid in identifying potential mechanisms requiring additional research and evaluation to better aid Clinical decisions for using coercive measures in ED agitation management.

    We conducted a prospective cohort study of adult patients aged 18 years or older with acute or escalating agitation during their ED visit. The clinical site was a 944-bed tertiary care academic referral cen- ter with an average annual adult ED volume of 100,000 visits. Consecu- tive patients were enrolled through observations performed during eight-hour blocks by four trained research associates (RAs) encompassing enrollment hours between 11 am to 2:59 am (for all seven days, 80 h per week). Eligibility included any clinical encounter that required a response from protective services personnel. In addition, the research associates regularly walked through the entire clinical unit to identify early cases of escalating patient agitation.

    In order to provide a comprehensive description of agitation events, we incorporated a broad spectrum of potential factors and clinical vari- ables to our observation instrument. We compiled our final list (Fig. 1) based on a synthesis of factors identified from our prior literature review

    Team Emergency Assessment Measure (TEAM) score [16]

    Fig. 1. Agitation Event Observation Instrument. Each factor and its method of data collection are listed. Categories correspond to levels of the ED agitation framework from Wong et al. [15]. The TEAM score is derived from Cooper et al. [16].

    Table 1

    Patient characteristics and clinical outcomes.

    Total N (%)

    N

    Patient characteristics

    95

    Median age, years (IQR)

    42 (32, 57)

    Gender

    Male

    59 (62.1)

    Female

    Race

    36 (37.9)

    White

    54 (56.8)

    Black

    29 (30.5)

    Other

    Ethnicity

    12 (12.6)

    Non-Hispanic

    78 (82.1)

    Hispanic

    Triage chief complaint

    17 (17.9)

    alcohol/drug use

    36 (37.9)

    Psychiatric/mental health

    22 (23.2)

    medical illness

    9 (9.5)

    Trauma

    9 (9.5)

    Delirium/altered mental status

    8 (8.4)

    Other/multiple

    EMS reports of alcohol/drug use

    11 (11.6)

    psychiatric illness, but also demonstrated a breadth of patient classes and diagnoses. Several staff and Environmental factors were found to be associated with use of coercive measures. Although reducing Use of restraints and sedatives is critical for patient safety, challenges specific to the ED may pose barriers for health workers to implement these non-coercive strategies. Behavioral techniques likely will need to be tailored specifically for the unique characteristics of ED agita- tion in order to effectively minimize use of coercion. We hope that this prospective characterization of agitation events can establish baseline measures for factors contributing to sedative and restraint use and help build future studies to measure agitation in a struc- tured, rigorous fashion.

    Presentations

    n/a.

    No/uncertain 33 (34.7)

    Yes 62 (65.3)

    Apparent impairment

    None

    12 (12.6)

    Alcohol/drug intoxication

    46 (48.4)

    Mental/psychiatric

    13 (13.7)

    Neurologic/cognitive

    5 (5.3)

    Multiple

    19 (20.0)

    Median prior ED visits in past year (IQR)

    3 (0, 8)

    of use of coercive measures [14] and the systems framework created for ED agitation management through mixed-methods analysis of staff data [15]. For the bivariable analyses, we conducted Pearson’s ?2 or Fisher’s exact tests for categorical data as appropriate, independent t-tests for normal continuous data, and Wilcoxon-Mann-Whitney U tests for non- parametric data. Correction of p-values for multiple comparisons was not made.

    Between June and August 2017, a total of 95 agitation events on unique patients were observed during enrollment hours (Table 1). The median age of the cohort was 42 years (IQR 32, 57), 62.1% were male, 56.8% were white, and 30.5% were black. For chief com- plaints, 23.2% presented were psychiatric, 9.5% were medical, 9.5% were trauma, 8.4% were delirium/altered mental status, 37.9% were alcohol or drug use, and 11.6% were other or had multiple complaints. EMS reported possible alcohol/drug use in 65.3% of visits. Observed apparent impairments included 48.4% alcohol/drug intoxication, 12.6% mental/psychiatric impairment, 5.3% neuro- logic/cognitive impairment, 20.0% multiple types, and 12.6% with no apparent impairment. Median number of prior ED visits in the past year was 3 (IQR 0, 8).

    Bivariable analyses with sedative and restraint use are listed in Table 2. No significant associations were seen for any patient character- istics. Within staff/healthcare team factors, significant higher median numbers of staff were involved for patients both with sedative use (6 vs 8, p b 0.01) and with restraint use (5 vs 8, p b 0.01). A significantly lower percentage of events with restraint use had an observable at- tempt at de-escalation versus events without restraint use (65.1% vs 93.8%, p b 0.01). Within environmental/systEMS factors, hallway occur- rence had a lower percentage for events with sedative use (9.8% vs 31.5%, p = 0.01).

    Our prospective cohort of Agitated patients in the ED included significant representation of alcohol/drug intoxication and

    Financial support

    Department of Emergency Medicine New Investigator Award, Yale School of Medicine; MCIC Vermont ED Patient Safety Award.

    Ambrose H. Wong, MD, MSEd*

    Jessica M. Ray, PhD Ambrose H. Wong Steven L. Bernstein, MD

    Department of Emergency Medicine, Yale School of Medicine, New Haven,

    CT, United States of America

    *Corresponding author at: Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave Suite 260, New Haven, CT 06519-

    1315, United States of America.

    E-mail address: [email protected].

    Lauren Crispino, BS

    Rowan University School of Osteopathic Medicine, Stratford, NJ, United

    States of America

    John Parker, BS

    Medical College of Georgia, Augusta, GA, United States of America

    Caitlin McVaney, BS Travis Whitfill, MPH

    Department of Emergency Medicine, Yale School of Medicine, New Haven,

    CT, United States of America Department of Pediatrics, Yale School of Medicine, New Haven, CT, United

    States of America

    Alana Rosenberg, MPH

    Yale School of Public Health, New Haven, CT, United States of America

    Joanne D. Iennaco, PhD, PMHNP-BC, APRN

    Yale School of Nursing, Orange, CT, United States of America

    25 November 2018

    https://doi.org/10.1016/j.ajem.2018.12.027

    References

    1. Holloman Jr GH, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med 2012;13:1-2.
    2. Miner JR, Klein LR, Cole JB, et al. The characteristics and prevalence of agita- tion in an urban county emergency department. Ann Emerg Med 2018;72: 361-70.

      Table 2

      Factors associated with sedative or restraint use.

      Sedatives used

      Restraints used

      No (%)

      Yes (%)

      p-Value

      No (%)

      Yes (%)

      p-Value

      N

      54

      41

      32

      63

      Patient characteristics

      Median age, years (IQR)

      44 (32, 59)

      38 (31, 51)

      0.45

      49 (37, 62)

      37 (31, 53)

      0.56

      Gender

      0.82

      0.96

      Male

      33 (61.1)

      26 (63.4)

      20 (62.5)

      39 (61.9)

      Female

      21 (38.9)

      15 (36.6)

      12 (37.5)

      24 (38.1)

      Race

      0.53

      0.93

      White

      33 (61.1)

      21 (51.2)

      19 (59.4)

      35 (55.6)

      Black

      14 (25.9)

      15 (36.6)

      9 (28.1)

      20 (31.7)

      Other

      7 (13.0)

      5 (12.2)

      4 (12.5)

      8 (12.7)

      Ethnicity

      0.72

      0.88

      Non-Hispanic

      45 (83.3)

      33 (80.5)

      26 (81.3)

      52 (82.5)

      Hispanic

      9 (16.7)

      8 (19.5)

      6 (18.8)

      11 (17.5)

      Chief complaint

      0.53

      0.67

      Alcohol/drug use

      22 (40.7)

      14 (34.1)

      12 (37.5)

      24 (38.1)

      Psychiatric/mental health

      14 (25.9)

      8 (19.5)

      7 (21.9)

      15 (23.8)

      Medical illness

      5 (9.3)

      4 (9.8)

      5 (15.6)

      4 (6.3)

      Trauma

      3 (5.6)

      6 (14.6)

      3 (9.4)

      6 (9.5)

      Delirium/altered mental status

      3 (5.6)

      5 (12.2)

      3 (9.4)

      5 (7.9)

      Other/multiple

      7 (13.0)

      4 (9.8)

      2 (6.3)

      9 (14.3)

      Reported alcohol/drug use (by EMS or patient)

      0.23

      0.69

      No/uncertain

      16 (29.6)

      17 (41.5)

      12 (37.5)

      21 (33.3)

      Yes

      38 (70.4)

      24 (58.5)

      20 (62.5)

      42 (66.7)

      Apparent impairment

      0.36

      0.06

      None

      8 (14.8)

      4 (9.8)

      6 (18.8)

      6 (9.5)

      Alcohol/drug intoxication

      28 (51.2)

      18 (43.9)

      14 (43.8)

      32 (50.8)

      Mental/psychiatric

      8 (14.8)

      5 (12.2)

      4 (12.5)

      9 (14.3)

      Neurologic/cognitive

      1 (1.9)

      4 (9.8)

      6 (18.8)

      3 (4.8)

      Multiple

      9 (16.7)

      10 (24.4)

      2 (6.3)

      13 (20.6)

      Median prior ED visits in past year (IQR)

      4 (0, 10)

      3 (0, 5)

      0.14

      6 (2, 10)

      2 (0, 7)

      0.11

      Staff/healthcare team factors

      Median number of staff involved (IQR)

      6 (4, 8)

      8 (6, 10)

      b0.01

      5 (3, 6)

      8 (6, 10)

      b0.01

      Team leader

      0.20

      0.56

      No

      42 (77.8)

      27 (65.9)

      22 (68.8)

      47 (74.6)

      Yes

      12 (22.2)

      14 (34.1)

      10 (31.3)

      16 (25.4)

      Any de-escalation attempted?

      0.21

      b0.01

      No

      11 (20.4)

      13 (31.7)

      2 (6.3)

      22 (34.9)

      Yes

      43 (79.6)

      29 (68.3)

      30 (93.8)

      41 (65.1)

      Reported staff familiarity with patient

      0.67

      0.08

      No

      32 (64.0)

      28 (68.3)

      16 (53.3)

      44 (72.1)

      Yes

      18 (36.0)

      13 (31.7)

      14 (46.7)

      17 (27.9)

      Mean total TEAM score (SD)

      27.7 (12.8)

      32.0 (9.1)

      0.08

      26.3 (14.1)

      31.2 (9.7)

      0.06

      Environmental/system factors

      Treatment step

      0.46

      0.12

      Triage

      23 (42.6)

      18 (43.9)

      12 (37.5)

      29 (46.0)

      During treatment

      29 (53.7)

      23 (56.1)

      18 (56.3)

      34 (54.0)

      Disposition

      2 (3.7)

      0 (0.0)

      2 (6.3)

      0 (0.0)

      Hallway occurrence

      0.01

      0.31

      No

      37 (68.5)

      37 (90.2)

      23 (71.9)

      51 (81.0)

      Yes

      17 (31.5)

      4 (9.8)

      9 (28.1)

      12 (19.0)

      Coercion into ED (per EMS or patient)

      0.10

      0.14

      No

      23 (46.0)

      11 (28.9)

      14 (50.0)

      20 (33.3)

      Yes

      27 (54.0)

      27 (71.1)

      14 (50.0)

      40 (66.7)

      Time of agitation event

      0.45

      0.33

      0700-1459

      6 (14.3)

      3(9.7)

      5 (17.2)

      4 (9.1)

      1500-2259

      32 (76.2)

      27 (87.1)

      21 (72.4)

      38 (86.4)

      2300-0659

      4 (9.5)

      1 (3.2)

      3 (10.3)

      2 (4.5)

      Total patients in the ED during agitation event

      86.5 (23.4)

      85.7 (21.3)

      0.87

      87.1 (21.4)

      85.7 (23.1)

      0.77

      Bold values indicates significance at p b 0.05.

      Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry 2003;48:330-7.

    3. Karger B, Fracasso T, Pfeiffer H. Fatalities related to medical restraint devices-

      asphyxia is a common finding. Forensic Sci Int 2008;178:178-84.

      Korczak V, Kirby A, Gunja N. Chemical agents for the sedation of agitated patients in the ED: a systematic review. Am J Emerg Med 2016;34:2426-31.

    4. 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.
    5. Chapman R, Ogle KR, Martin C, et al. Australian nurses’ perceptions of the use of manual restraint in the Emergency Department: a qualitative perspective. J Clin Nurs 2016;25:1273-81.
    6. van der Zwan R, Davies L, Andrews D, Brooks A. Aggression and violence in the ED: issues associated with the implementation of restraint and seclusion. Health Promot J Austr 2011;22:124-7.
    7. Phillips JP. Workplace Violence against health care workers in the United States. N Engl J Med 2016;374:1661-9.
    8. Downey LV, Zun LS, Gonzales SJ. Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. Gen Hosp Psychiatry 2007;29:470-4.
    9. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med 2003;24:119-24.
    10. Kowalenko T, Gates D, Gillespie GL, et al. Prospective study of violence against ED workers. Am J Emerg Med 2013;31:197-205.
    11. May DD, Grubbs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs 2002;28:11-7.
    12. Wong AH, Taylor RA, Ray JM, Bernstein SL. Physical Restraint Use in Adult Pa- tients Presenting to a General Emergency Department. Ann Emerg Med 2018

      Aug 14. https://doi.org/10.1016/j.annemergmed.2018.06.020 pii: S0196-0644

      Fracture

      119 (57.2%)

      (18)30551-1.

      Open wound

      83 (39.9%)

      [15] Wong AH, Ruppel H, Crispino L, et al. Deriving a Framework for Systems-Based Ap-

      Contusion/abrasion

      77 (37.0%)

      proach to AgitatED patient care in the Emergency Department. Jt Comm J Qual Pa-

      Crush injury

      40 (19.2%)

      tient Saf 2018;44:279-92.

      Head injury

      37 (17.8%)

      [16] Cooper S, Cant R, Porter J, et al. Rating medical emergency teamwork performance:

      Sprain/strain

      35 (16.8%)

      development of the Team Emergency Assessment Measure (TEAM). Resuscitation

      Chest injury

      19 (9.1%)

      2010;81:446-52.

      Extremity amputations

      17 (8.2%)

      Abdominal injury

      14 (6.7%)

      Dislocation

      9 (4.3%)

      Burn

      8 (3.9%)

      Other

      9 (4.3%)

      Table 1

      injury characteristics.

      Number of patients (%)

      Life on the farm: A community-based study of tractor-related injuries and fatalities

      Agriculture is a particularly dangerous industry when taking into ac- count occupational injury and fatality rates. In 2010, the fatality rate for agriculture was 27.9 per 100,000 workers, which is dramatically higher than the reported incidence of 3.6 deaths per 100,000 workers for all other occupations combined [1]. Tractor mishaps are a significant cause of machinery-related injuries on farms, accounting for an esti- mated 4-14% of nonfatal injuries and one-third of fatal agricultural inju- ries [2]. Safety equipment such as rollover protective structures, master shields covering the power take-off (PTO), and driveline and power input connection guards have been introduced in newer tractors in order to help prevent injury [3]. However many tractors currently in use were manufactured prior to these installments and operators may find it too expensive or cumbersome to have their equipment fitted with these devices [3]. Misuse of equipment, having children on or around these machines, and use of tractors on public roads also intro- duce an increased chance for injury or death [3]. Emergency department (ED) personnel may have little or no familiarity or knowledge about the hazards of agricultural work, including what to expect with tractor- related injuries. The purpose of this study was to characterize the inci- dence, injury characteristics, and outcomes of tractor-related injuries in West Michigan.

      We conducted a retrospective cohort analysis of ED patients with a tractor-related injury seen in seven participating hospitals in West Michigan from January 2002 to August 2016. Data was collected on de- mographics, mechanisms of injury, diagnoses, treatment provided, and mortality rate. Additional farm fatalities secondary to tractor-related in- cidents were identified using data from the Michigan Fatality Assess- ment and Control Evaluation (MIFACE) research program [4]. These fatalities occurred in West Michigan during the study period but were not seen in participating hospitals. Descriptive statistics and frequency tables were used to describe the key quantitative and qualitative variables.

      We evaluated 208 patients presenting to participating hospitals with 507 tractor-related injuries during the study period. The mean age was

      42.0 +- 20.0 with a range of 3-86 years. Twenty-nine patients (13.9%) were b18 years of age and 11 (5.3%) were N70 years old. A total of 73 pa- tients (35.1%) had injuries classified as severe (trauma priority 1 or 2). Leading types of injury in all age groups were fractures (n = 119, 57.2%) followed by open wounds and contusions/abrasions (Table 1). The majority of fractures involved the upper or lower extremities (79.3%), followed by fractures to the spine (11.5%), pelvis (4.8%) and skull (4.4%).

      Overall, the most common mechanisms of nonfatal tractor-related injuries were having an extremity pinned, caught or lacerated (n = 81, 38.9%), followed by tractor run over (n = 34, 16.4%) (Table 2). The frequencies of the injury mechanisms were different in children with

      the most common mechanism being a fall/jump/ejection (n = 16, 55.2%), followed by a run over (n = 7, 24.1%). A total of 76 patients (36.9%) were admitted to the hospital (LOS 7.9 +- 7.7 days) with four subsequent fatalities (1.9%).

      According to MIFACE, a total of 119 agriculture fatalities occurred in Western Michigan between 2002 and 2016, and 63 (52.9%) were tractor-related [4]. Causes of death included tractor overturn (46%), run over (16%), and road collisions (11%), among others. Documented reasons for these fatalities include a relative lack of safety training and seat belt use, fatigue and carelessness, lack of emergency preparedness, and exposure of High risk groups like children and elderly to hazardous environments.

      Our study supports facts previously found in that various pro- cesses may lead to a tractor-related injury, and these mechanisms vary by age and impact on the severity of the resulting injury [1]. Although fractures and soft-tissue extremity wounds are com- monly reported, in our study approximately one-third of patients had severe traumatic injuries. ED physicians must be prepared to handle a wide variety of injuries in tractor-related incidents. A par- ticularly disturbing aspect of this study is the frequency of injuries to children, who make up a substantial portion of rural farm staff. It is common for children to work in agriculture at a young age, espe- cially since they are protected by Federal labor laws implemented by the US Department of Labor to a lesser extent than children in other areas of the workforce. For example, laws declare it hazard- ous for children under 16 years of age to operate a tractor and other heavy machinery on farms, but in other realms, individuals must be 18 or older to operate hazardous equipment [5]. Investiga- tion of unsafe working conditions is often completed by the Office of Safety and Health Administration (OSHA), of which there are both Federal and State offices [6]. Reports to these offices must be taken seriously and investigated thoroughly. Ensuring proper training and oversight for agricultural workers is a must. It would also be prudent to ensure heavy machinery such as tractors either

      Table 2

      Tractor related injuries in West Michigan 2002-2016.

      Number of patients (%)

      Pinned/caught/cut

      81 (38.9%)

      Tractor – run over

      34 (16.4%)

      Tractor – fall/jump/ejection

      30 (14.4%)

      Tractor – overturn

      16 (7.7%)

      Struck

      8 (3.8%)

      Tractor PTO entanglement

      7 (3.4%)

      Road collisions

      3 (1.4%)

      Other

      29 (13.9%)

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