Ambrose H. Wong, MD, MSEd; Lynn P. Roppolo, MD; Bernard P. Chang, MD, PhD; Kimberly A. Yonkers, MD; Michael P. Wilson, MD, PhD; Seth Powsner, MD; John S. Rozel, MD, MSL


Western J Emerg Med. 2020;21(4):795-800. 

In This Article

Abstract and Introduction


The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.


The World Health Organization declared the novel coronavirus disease 2019 (COVID-19) as a pandemic in March 2020, with rising infection rates around the world and within the United States.[1] This outbreak has radically altered delivery of care in emergency departments (ED), as efforts continue to prevent transmission and combat the disease.[2] Although attention has appropriately been focused on clinical management and emergency preparedness during COVID-19, this historic event has also had significant consequences for mental health that may be easily overlooked. Unprecedented hardship due to ongoing fears of exposure, threats to personal safety, and limited access to resources have broad psychosocial impact on patients and healthcare workers alike.[3] These changes can significantly affect how individuals with behavioral symptoms may present and what management strategies are most appropriate during the care of behavioral emergencies.

Agitation is one of the most common behavioral emergencies in the ED, with 1.7 million episodes[4] annually in emergency settings and a recent estimated overall ED prevalence of 2.6%.[5] Agitated patients are among the most challenging to evaluate and manage by emergency physicians, as their excessive psychomotor activity can escalate quickly into violent acts and physically aggressive behavior.[6] Nationwide, 78% of emergency physicians reported being targets of workplace violence in the previous 12 months.[7] In 2012, the American Association for Emergency Psychiatry (AAEP) published Project BETA (Best practices in Evaluation and Treatment of Agitation), consisting of a landmark series of consensus guidelines to provide effective and safety-minded strategies for agitation management with the best interests of the patient in mind while ensuring the safety of healthcare workers.[4] The Project BETA guidelines focus on a noncoercive approach to manage these patients with an emphasis on de-escalation, safety and risk assessment, and addressing potentially life-threatening medical concerns.[8,9] Forced medication and physical restraint are reserved as the last resort to control agitation symptoms, given that their use is associated with elevated risk for both patients and staff.[10]

The management principles encapsulated within Project BETA remain applicable in the COVID-19 era, but adaptations are needed in light of the unique circumstances and environmental conditions due to the pandemic. Given the possibility of a projected lengthy timeline before this outbreak abates,[11] awareness of its effects on the management of agitation is needed now to ensure safety of both patients with behavioral symptoms and frontline healthcare workers caring for them. On behalf of AAEP, we aim to highlight in this work some important unique considerations for the management of agitation in the ED during COVID-19 (Table 1).