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Why You Should Know About Project BETA: Best Practices in Evaluation and Treatment of Agitation

Faculty Perspectives: Coping with Agitation Associated with Schizophrenia and Bipolar Disorder: How Can Healthcare Professionals Help Their Patients?

Agitated patients are at risk for becoming violent or aggressive, and causing harm to themselves, others, and property. In October 2010, the American Association for Emergency Psychiatry embarked on Project BETA (Best Practices in Evaluation and Treatment of Agitation) to address the inconsistency in treatment approaches for agitation, which can vary widely by region and institution.1 Project BETA provides guidelines for the medical evaluation and triage of the agitated patient,2 psychiatric evaluation of the agitated patient,3 verbal de-escalation of the agitated patient,4 psychopharmacologic approaches to agitation,5 and the use and avoidance of seclusion and restraint.6 These guidelines are available online and are free to access.

Guidelines for the medical evaluation and triage of the agitated patient provide a comprehensive algorithm to help clinicians consider the numerous medical and psychiatric conditions that may cause agitation.2 Some of these causes are life-threatening and require special attention. Guidance is also offered on the workup of agitation when a medical etiology is suspected or when etiology is unclear.

Psychiatric evaluation of an agitated patient may be challenging, and usually cannot be completed until the patient is calm enough to participate in a psychiatric interview.3 Guidance for evaluating an agitated patient is presented through a 2-step process. Initially, a rapid evaluation attempts to determine the most likely cause of agitation to guide preliminary interventions to calm the patient. Once the patient is calmed, a more extensive psychiatric assessment may be conducted.

Verbal de-escalation is a fundamental intervention in the management of agitated patients.4 The goals are to avoid the routine use of restraints and involuntary medication. A 3-step approach is described. First, the patient is verbally engaged; then a collaborative relationship is established; and finally, the patient is verbally de-escalated out of the agitated state.4 Emphasis is placed on ensuring the safety of the patient, staff, and others in the area; helping the patients manage his/her emotions and distress and maintain or regain control of his/her behavior; and avoiding coercive interventions by medical staff that may paradoxically escalate agitation. The “10 domains of de-escalation” include: (1) respecting personal space, (2) avoiding provocation, (3) establishing verbal contact, (4) conciseness in communications, (5) identifying wants and needs, (6) careful listening, (7) agreeing or agreeing to disagree, (8) setting limits, (9) offering choices and optimism, and (10) debriefing for both patients and staff.

Psychopharmacologic approaches to managing agitated patients should be based on an assessment of the most likely cause of the agitation.5 If it is a result of a medical condition or delirium, clinicians should first attempt to treat this underlying cause instead of simply medicating the patient with antipsychotics or benzodiazepines. Oral medications are recommended over intramuscular injections, provided the patient is cooperative and there are no medical contraindications to their use. Antipsychotics are indicated as first-line management for acute agitation with psychosis of psychiatric origin, and certain second-generation antipsychotics, with good evidence to support their efficacy and lack of adverse events, are preferred over first-generation antipsychotics. It is important to note that the Project BETA guidelines were created before the availability of a new inhaled antipsychotic drug7 or the availability of research using a sublingual atypical antipsychotic drug for the rapid control of agitation.8

Avoiding seclusion and restraint is an important issue, and Project BETA offers guidance on this as well.6 The report on this topic includes a discussion of the Centers for Medicare and Medicaid Services guidelines regulating the use of seclusion and restraint in medical behavioral settings, as well as outlining the negative consequences of this type of intervention to patients and staff. The report also offers an algorithm designed to help the clinician determine when seclusion or restraint is most appropriate.




References

  1. Holloman GH Jr, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2012;13:1-2.
  2. 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.
  3. Stowell KR, Florence P, Harman HJ, Glick RL. Psychiatric evaluation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA psychiatric evaluation workgroup. West J Emerg Med. 2012;13:11-16.
  4. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA de-escalation workgroup. West J Emerg Med. 2012;13:17-25.
  5. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA psychopharmacology workgroup. West J Emerg Med. 2012;13:26-34.
  6. Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA seclusion and restraint workgroup. West J Emerg Med. 2012;13:35-40.
  7. Citrome L. Addressing the need for rapid treatment of agitation in schizophrenia and bipolar disorder: focus on inhaled loxapine as an alternative to injectable agents. Ther Clin Risk Manag. 2013;9:235-245.
  8. Pratts M, Citrome L, Grant W, et al. A single-dose, randomized, double-blind, placebo-controlled trial of sublingual asenapine for acute agitation. Acta Psychiatr Scand. 2014;130:61-68.
Last modified: August 30, 2021