Prepare for the Worst

De-escalation Training Arms Hospitalists With Measures to Calm Agitated Patients

Karen Appold


The Hospitalist. 2015;19(3):30-31. 

In This Article

The Most Dangerous Circumstances

According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the "takedown," which is when staff attempt to tackle and restrain an agitated patient.[3]

"If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes," says Dr. Zeller, who co-authored the article. "To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach."

As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.

The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.

"Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications," Dr. Zeller says.

As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.[4]