Don't Get MAD: Managing Agitation With De-Escalation Training in a Pediatric Emergency Department

Acute agitation is a behavioral health emergency necessitating timely, effective intervention. Consensus guidelines recommend de-escalation techniques before restraint use. We examined the impact of de-escalation training on attitudes, knowledge, and behaviors of interdisciplinary staff caring for agitated patients in the pediatric emergency department (PED).

Asynchronous, multi-faceted de-escalation training interventions were delivered biweekly in an urban tertiary care PED as one facet of a quality improvement initiative to reduce disparities in physical restraint use. An electronic survey including the Management of Aggression and Violence Attitude Scale (MAVAS) plus questions on knowledge of and behaviors with pediatric agitation was distributed before and after the training interventions. Baseline and post-intervention survey results were compared, measuring changes in attitudes, knowledge, and self-reported behaviors.

Sixty-one of 148 (41%) eligible participants completed the baseline survey and 44 (30%) completed the post-intervention survey. Post-intervention, participants were less likely to agree that it is difficult to prevent patients from becoming violent or aggressive (OR=0.31, 95% CI: 0.14-0.70) or that internal causative factors contribute to patient aggression (OR=0.50, 95% CI: 0.26-0.97). Post-intervention, respondents were more likely to recognize existing racial disparities in pediatric restraint use (OR=3.41, 95% CI: 1.64-7.09) and to believe that agitated patients were verbally de-escalated without restraint use often (OR= 2.11, 95% CI: 1.02-4.37).

After implementing asynchronous, multi-faceted de-escalation training, PED staff positively shifted their attitudes of children with acute agitation, improved knowledge about disparities in their care, and were more likely to believe that verbal de-escalation of agitated patients without restraint use was used often. De-escalation training can be easily implemented and impactful, and these data warrant further investigation into best de-escalation practices.