Structured team approach to the agitated patient in the emergency department

Behavioural disturbance and aggression in the ED is an increasing problem. The present study describes the characteristics of patients with acute behavioural disturbance and their emergent treatment in an ED with a structured team approach.

This was a retrospective review of acute behavioural emergencies that required response from the Code Black (CB) Team (duress response team) in the ED during 2006. The hospital security log and hospital incident-reporting system identified all documented CB, and the patients' medical records were reviewed. Information extracted included patient demographics and presenting complaint, details of the CB, the use of pharmacological sedation, physical restraint and patient disposition. Injuries to hospital staff were also extracted.

There were 122 patients, median age 32 years (interquartile range: 24-43 years, range: 14-81 with 71 male patients (58%) who accounted for 143 CB activations. The primary problems were deliberate self-poisoning or self-harm (38%), alcohol and illicit drug intoxication (33%) and psychiatric, organic illness and drug withdrawal (29%). One hundred and eight (89%) patients had a past history of alcohol/illicit drug abuse or psychiatric illness. Indications for CB activation were threatening harm to others or behaving violently in 67% of cases. Combined pharmacological sedation and physical restraint were required on 66 (46%) occasions, pharmacological sedation alone on 20 (14%), physical restraint alone on 14 (10%) and neither on 43 (30%) occasions. Benzodiazepines were most commonly used for initial sedation, including i.m. (29%), i.v. midazolam (20%), diazepam (42%) and antipsychotics (9%), most commonly droperidol. More diazepam and droperidol were used for subsequent pharmacological sedation. A staff member was injured on only one occasion (0.7%).

Acute behavioural disturbance was common in the present study, and underlying causes were predominantly organic in nature. A team approach appears to be valuable in managing these incidents.