In a 2018 poll by the American College of Emergency Physicians, nearly half of emergency medicine physicians surveyed reported having been assaulted while at work in the emergency department. Further, more than forty percent of these respondents believe that psychiatric patients are responsible for over 50% of these assaults. To protect both staff and patient safety, understanding how to manage acutely agitated patients is crucial.
Best Practices in the Evaluation and Treatment of Agitation (BETA) are evidence-based guidelines to treat acutely agitated patients developed by the American Association of Emergency Psychiatry, as cited by Western Journal of Medicine. Rather than defaulting to the traditional “restrain and medicate” approach, BETA emphasizes a systematic, patient-centered strategy.
The 2022 article Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation) in the Journal of the American College of Emergency Physicians outlines the following approach:
Initial Assessment:
- Ensure staff safety first
- Screen for immediate life threats
- Look for medical causes of agitation (including trauma, infection, metabolic disorders)
- Obtain vital signs and focused history when safe
De-escalation Techniques:
- Use calm, clear voice
- Maintain non-threatening posture
- Show empathy and respect
- Listen actively
- Offer choices when possible
- Set clear behavioral expectations
Medication Approach For psychotic agitation:
- First-line: Second-generation antipsychotics (olanzapine 10mg IM)
- Alternative: Haloperidol 5mg IM with benztropine for side effects
Medication Approach: For non-psychotic agitation:
- Benzodiazepines (midazolam 5mg IM/IV or lorazepam 2mg IM/IV)
Physical Restraints (Last Resort):
- Requires minimum of five trained staff
- One person per extremity plus head control
- Regular monitoring required
- Document clinical justification
- Maintain patient dignity
In addition to this effective BETA approach, a 2023 article in Psychiatry Online, Updates in the Assessment and Management of Agitation, highlights more refined guidelines for managing agitated patients. New developments include pediatric-specific protocols, treatments for distinct patient populations, and both new and reconsidered medications like droperidol. Researchers have also examined bias and equity in agitation management.
The shift from “restrain and medicate” treatment of acutely agitated patients to this systematic approach has shown promising results in reducing workplace violence while improving patient care. Success requires organizational commitment, staff training, and a culture of safety to ensure that both patients – and physicians – are treated with respect and dignity.
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