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Published in CenterView on October 08, 2012

Project BETA encourages holistic approach to treating distressed patients

By Jack Mazurak

When agitated patients come into emergency departments, many end up physically restrained and over sedated with medications.

But a recent series of articles called Project BETA – Best practices in Evaluation and Treatment of Agitation – published in the Western Journal of Emergency Medicine, lays out a more patient-centered, non-coercive treatment guideline.

HollomanDr. Garland Holloman, associate professor of psychiatry and medical director of the psychiatric emergency service, chaired a task force that wrote Project BETA. He said common causes of agitation include exacerbations of psychiatric illness, substance intoxication or withdrawal and a variety of medical problems, including neurological conditions, infections, metabolic disturbances, toxin exposure and more.

“In the past, the biggest focus for treatment of agitation was on pharmacological intervention,” Holloman said.

Project BETA addresses pharmacological and other aspects of managing agitation. Though some hospitals already employ techniques similar to Project BETA’s, the publication marks the first compilation of a comprehensive approach backed by the American Association for Emergency Psychiatry.

Agitated patients show nonspecific verbal and motor behaviors but only a small number become aggressive, Holloman said. Emergency departments nationally see about 1.7 million agitation cases a year, according to the project’s authors.

“Not infrequently, an agitated person comes in and there’s already a high level of activity in the ED,” Holloman said. “The person is agitated and scared. A lot of these people have been traumatized repeatedly during their lives – abused as children, abused in relationships or abused on the streets.

“They are easily seen as just being disruptive, and not as human beings who have needs that we, as caregivers, are there to address.”

Then they can be traumatized by a system that is supposed to help them. Physical takedowns and restraint by police, EMTs and ED staff and forced injection of medications just add to their trauma and make them distrustful and afraid of the system.

“It repeats over and over. Our intent with this project was to develop a more humane and
patient-centered approach,” he said.

“We’re beginning to see restraint not as a treatment modality but as a treatment failure. We can’t get rid of restraint altogether because there are patients who are violent. But a lot of them who we think are going to get violent are very agitated but not aggressive or dangerous unless they feel threatened.”

Project BETA began about two years ago when Dr. Scott Zeller, AAEP past president, set a goal to develop new agitation treatment guidelines. Holloman, now an AAEP board member, volunteered to chair the multidisciplinary task force that wrote the papers.

The task force set up five workgroups and produced an overview and five papers that lay out the guidelines. They are Medical Evaluation and Triage, Psychiatric Evaluation, Verbal De-escalation, Psychopharmacology of Agitation, and Use and Avoidance of Seclusion and Restraint.

Project BETA recommends annual training for nurses and physicians involved in treatment of agitated patients. Holloman said he’d like to see all first-responders trained, from law enforcement to EMTs and paramedics.

From a training perspective, Holloman said, de-escalation can be practiced with mildly agitated patients until the skills are learned.

The Western Journal of Emergency Medicine published Project BETA in February. Alexza Pharmaceuticals provided an unrestricted educational grant to solely assist with printing and distribution.

A full version of Project BETA is free online at http://escholarship.org/uc/uciem_westjem?volume=13;issue=1.