Overview of Project BETA: Best practices in Evaluation and Treatment of Agitation

Agitation in emergency settings is a major concern, with a staggering 1.7 million episodes annually in the United States alone. Agitated individuals are at risk of becoming aggressive and violent, and of causing harm to themselves, others, and property. Agitation is a leading cause of hospital staff injuries and can cause untold physical and psychological suffering for patients and all those nearby. Yet, despite the pervasiveness of agitation, there is surprising inconsistency in treatment approaches, which can vary widely by region and institution. Many facilities now use techniques such as intervention teams, which are paged instantly when there is an agitated patient, or ‘‘management of assaultive behavior’’ protocols that seek to engage patients into voluntarily accepting treatment. However, far too many agencies still treat all episodes of agitation in a fashion that might best be described as ‘‘restrain and sedate.’’ Although regulatory agencies and advocacy groups have called for a reduction in the use of restraint and less coercion in psychiatric treatment, there has been inadequate discussion regarding effective, alternative management of the agitated patient. Clearly, a void has existed in quality guidelines for the treatment of agitation. To help address this need, the American Association for Emergency Psychiatry (AAEP), in October 2010, embarked on Project BETA (Best practices in Evaluation and Treatment of Agitation). Recruiting dozens of emergency psychiatrists, emergency medicine physicians, and others associated with acute care of the mentally ill, Project BETA has intended to provide guidelines that are not only effective and safety minded but also in the best interests of the patient. Creating quality guidelines for agitation is no easy task. Unlike most disease states, the research database on agitation is quite limited. Much of this can be ascribed to the difficulty in obtaining the informed consent necessary for most clinical studies. How does one get informed consent from a combative, threatening individual? Further, in those studies that do involve informed consent, questions might arise as to the severity of subjects’ levels of agitation, if indeed they were even able to comply with the consent process. Given these obstacles, the Project BETA team determined that the best guidelines would be ascertained through a synthesis of the best available research with the expert consensus of seasoned clinicians. Until now, existent guidelines for agitation have focused solely on medication strategies. Yet, agitation can result from myriad origins, and its treatment is multifaceted, with pharmacology only playing 1 part. The Project BETA members recognized that to truly address the agitation spectrum, for the first time, guidelines should be developed that would direct clinicians in all interventional aspects, including triage, diagnosis, and verbal de-escalation, as well as medicine choices. Thus, 5 study workgroups were developed by using the basic approaches of emergency psychiatry as a foundation. The treatment goals of emergency psychiatry are as follows: (1) exclude medical etiologies for symptoms; (2) rapid stabilization of the acute crisis; (3) avoid coercion; (4) treat in the least restrictive setting; (5) form a therapeutic alliance; and (6) appropriate disposition and after-care plan. The 5 workgroups, projected in the order of following a patient through an intervention, were established to address the following topics: