Clinical Fellow Yale New Haven Children's Hospital NEW HAVEN, Connecticut, United States
Background: Acute agitation is a behavioral emergency frequently encountered in pediatric emergency departments (PEDs). With increasing prevalence of childhood mental health conditions and subsequent increase in PED visits for psychiatric-related concerns, timely and effective de-escalation is imperative. Objective: To determine frequency and perceived effectiveness of de-escalation practices used in patient care after implementing a multifaceted intervention and to examine changes in attitudes, knowledge, and experience among interdisciplinary PED staff caring for agitated patients. Design/Methods: An electronic survey including the Management of Aggression and Violence Attitude Scale (MAVAS) and 12 additional questions on knowledge and experience of pediatric agitation was distributed to PED staff. Educational material was delivered in person or via email every 2 weeks (figure 1). A follow-up survey was distributed 2 months later. Results of pre- and post-surveys were compared. Results: Sixty-five participants completed the initial survey, 55 completed the post-survey, and 25 completed both (table 1). Listening closely (88%), respecting personal space (86%), and establishing verbal contact (84%) were the most frequently used de-escalation practices; avoiding provocation was found to be most effective (79%). A visual aid with de-escalation tips was the most reviewed educational product; 36% of participants found it to be quite or extremely helpful. Most participants (78%) used de-escalation practices with patients in the 3 months post-intervention. Significant shifts in attitudes were noted in 3 items on the MAVAS. More participants disagreed (1) it is difficult to prevent patients from becoming aggressive (68% vs. 40%, p≤ 0.02). Participants agreed violent patients are restrained for their own safety but shifted towards disagreement (84% vs. 52%, p≤ 0.01). More participants agreed (3) gender mix of staff is important in management of aggression (56% vs. 80%, p≤ 0.05). Staff attitudes that high quality care was “often or always” provided to pediatric behavioral health patients increased after the intervention (36% vs. 68%, p≤ 0.02) and more agitated pediatric patients were reported to be “often or always” verbally de-escalated without pharmacologic or physical restraint (32% vs. 64%, p≤ 0.01).
Conclusion(s): Quality of patient care and successful use of verbal de-escalation alone significantly improved after educational training. Future efforts should focus on identifying the most effective verbal de-escalation strategies and training methods to examine the impact of de-escalation training on patient outcomes.
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