Simulated Patients Teach Real Lessons in Managing Agitation

Megan Brooks

May 04, 2014

NEW YORK ― A course designed to give senior medical students and psychiatry residents the confidence and skills to effectively manage agitated patients is proving successful at Emory University School of Medicine in Atlanta, Georgia.

A group of students and interns who took the course, which uses realistic, simulated patient encounters and immediate feedback, reported greater levels of knowledge and comfort in dealing with agitated patients.

"One of my co-interns when I first started as a resident was actually assaulted on one of her night shifts, which was a really scary event for all of us and really highlighted for me the need to not only know how to deal with these patients but to feel like I was prepared to see these patients," lead author Andrea L. Crowell, MD, PGY-4 psychiatry resident at Emory's Department of Psychiatry and Behavioral Services, told Medscape Medical News.

The findings were presented here at the American Psychiatric Association (APA) 167th Annual Meeting.

Confidence Booster

Behavioral agitation is a common clinical problem affecting residents of most specialties. Yet fewer than 80% of psychiatry residents and only 30% of nonpsychiatry residents receive formal training in managing violent patients, and this training has been judged to be inadequate, the authors note.

Dr. Crowell and coauthor Robert O. Cotes, MD, assistant professor of psychiatry and behavioral sciences and associate director of psychiatry residency education at Emory, reported on 16 fourth- year medical students and 13 psychiatric interns who took Emory's agitation management course.

A 45-minute instructional session is followed by 4 experiential scenarios with "standardized" patients trained to realistically mimic an agitated patient suffering from delirium, substance abuse, mania, and psychosis in hospital and clinic settings.

Each learner participated in 1 to 2 scenarios while being observed via video by peers and a senior resident and faculty member who led a feedback session immediately after each interaction.

Thirteen medical students (81.3%) and 12 residents (92%) completed pre- and postcourse self-assessments in which they rated their comfort in managing agitated patients; their knowledge of causes of agitation; their familiarity with verbal and behavioral deescalation techniques; and their knowledge of drug therapy for agitation. All assessments were rated on a scale from 1 to 7, with 1 representing "poor" and 7 representing "excellent."

Prior to the course, self-ratings for medical students averaged 3.7 in comfort, 4.1 in knowledge of causes, 3.6 in de-escalation, and 3.5 in pharmacology. Postcourse assessment scores increased to 5.2, 5.6, 5.5, and 5.0, respectively. Improvement in each area of self-assessment was significant (P ≤ .007).

For residents, precourse self-ratings averaged 4.2 in comfort, 3.6 in knowledge of causes, 3.5 in de-escalation, and 3.6 in pharmacology. Postcourse assessment scores increased to 5.5 in the first 3 categories and to 5.2 in pharmacology. Again, improvement in each area was significant (P ≤ .009).

Participants rated the course favorably (5.7 out of 7). Participant feedback suggested that the realism of the simulations and immediate feedback are key features of the course, the authors say.

"Right now, we give this course to fourth-year medical students who are just about to graduate and go on to residency and PGY-1 residents just starting their internship," Dr. Cotes told Medscape Medical News. "We try to time it very early in the year, before they have all that many clinical interactions with agitated patients."

One goal going forward is to expand use of standardized patients for skills competency assessment.

The study was sponsored by a Fund for Innovative Teaching (FIT) grant at Emory University. Dr. Crowell has been awarded the 2014 APA Lilly Research Fellowship. Dr. Cotes reports no relevant financial relationships.

American Psychiatric Association's 2014 Annual Meeting. Abstract 72. Presented May 3, 2014.


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