Lynn P. Roppolo, MD, remembers years ago when emergency department staff, including doctors and nurses, would be physically assaulted almost weekly.
Roppolo works in the emergency department at Parkland Hospital and Children’s Medical Center and is a professor in the Department of Emergency Medicine at UT Southwestern. Parkland’s ED is one of the busiest EDs in the country with more than 240,000 patient visits annually.
According to Roppolo, a common scenario typically consisted of a patient escalating into a violent rage and several staff and security would have to hold them down to administer calming medications. Restraints and medications were often the first line of defense to control severely agitated and potentially violent behaviors.
Roppolo, first author on the review, “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),” published last year in the Journal of the American College of Emergency Physicians Open, said she has completely changed her approach to agitated ED patients and has witnessed only one physical assault in the last five years because of it.
In an interview with Nurse.com, Roppolo said her turning point came after reading the series of articles called, “Best Practices in the Evaluation and Treatment of Agitation (BETA),” which were written by experts in emergency medicine and psychiatry and published in the Western Journal of Emergency Medicine in 2012.
From the articles, she learned:
- The power of de-escalation in reducing acute agitation
- Risk assessment, which should dictate the best management strategies
- The antiquated approach of “restrain and medicate” should be the last resort
- How to safely control the behavior of a severely agitated patient if restraint and calming medications are necessary
“De-escalation is a type of conflict resolution or crisis resolution. It is a combination of strategies and techniques used to reduce a patient’s anxiety, agitation, and aggression,” said Tiffany Carder MSN, RN, CEN, Clinical Nurse Educator, Emergency Services at Parkland Health and Hospital System, and an author on the review with Roppolo.
Although different approaches and acronyms exist to guide de-escalation, Roppolo has a commonsense approach that she has used with success.
“De-escalation requires empathy, compassion, kindness, partnering, understanding, and a sincere willingness to help,” Roppolo said. “Try to understand why the patient in front of you is agitated and treat them like you would want to be treated if you were in their shoes.”
Patients are often frightened and paranoid, so one verbal approach is to repeatedly tell them that they are safe and you want to help. Nonverbal communication is just as important as what a nurse says and should relay the same message, according to Roppolo.
The goal is to bring a patient to a state where the staff can safely provide care. However, sometimes the best practices aren’t always in place. Australian suthors of the 2021 paper, “Exploring Staff Experiences: A Case for Redesigning the Response to Aggression and Violence in the Emergency Department,” published in the International Emergency Nursing journal, wrote, “Our findings show that there are no guidelines …read more
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