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

[West J Emerg Med. 2012;13(1):1–2.

Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup

Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units, and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA (Best practices in Evaluation and Treatment of Agitation) is noncoercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior. In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment primarily of acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions

The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup

Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause of the agitation. If agitation results from a delirium or other medical condition, clinicians should first attempt to treat the underlying cause instead of simply medicating with antipsychotics or benzodiazepines

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the “10 domains of de-escalation.

Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup

Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA is non-coercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior.In this paper, the authors discuss several aspects of seclusion and restraint, including review of CMS guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff and a review of quality improvement and risk management strategies that have been effective in decreasing its use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment of primarily acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions. [West J Emerg Med. 2012;13(1):35–40.

Unresolved PTSD in a Hispanic Woman Presenting with Test Anxiety

This article illustrates the unique symptom presentation and outpatient treatment of posttraumatic stress disorder (PTSD) in a Hispanic female. The patient was referred to therapy to address problems with concentration and difficulties related to test-taking. A motivational interviewing-based assessment was conducted and the case was conceptualized in a cognitive- behavioral framework. After resolution of test-taking anxiety, additional anxiety symptoms emerged, including subclinical panic disorder and evidence of unresolved PTSD. Prolonged Exposure was initiated to successfully treat residual trauma-related symptoms. Recommendations for assessment and treatment of individuals with a trauma history are provided, with an emphasis on the need for sensitivity to cultural issues

การประชุมร่วมของสมาคมภาวะฉุกเฉินทางจิตเวชของประเทศอเมริกาในโครงการ BETA Psychopharmacology เกี่ยวกับเรื่อง……จิตเภสัชวิทยาของภาวะกายใจไม่สงบ

ภาวะกายใจไม่สงบ(agitation)พบบ่อยทั้งในภาวะฉุกเฉินทางอายุรกรรมและจิตเวช การรักษาพยาบาลได้อย่าง เหมาะสมในกรณีดังกล่าวถือเป็นสมรรถนะหลักอย่างหนึ่งของแพทย์เวชศาสตร์ฉุกเฉิน ในบทความนี้ผู้นิพนธ์ ได้รวบรวมการใช้ยารักษาโรคจิตในกลุ่ม first-generation second-generation และยา benzodiazepines เพื่อใช้ ในการรักษาภาวะกายใจไม่สงบ(agitation)ชนิดเฉียบพลัน รวมทั้งนำ�เสนอแนวทางจำ�เพาะในการรักษาภาวะกาย ใจไม่สงบ(agitation)ที่สัมพันธ์กับภาวะต่างๆได้แก่ การได้รับสารพิษ ภาวะจิตเภท อาการเพ้อ(delirium) รวมทั้ง เกิดขึ้นโดยไม่ทราบสาเหตุ การใช้ยาเพื่อรักษาภาวะกายใจไม่สงบควรพิจารณาตามสาเหตุก่อโรคที่เป็นไปได้มาก ที่สุด ถ้าภาวะกายใจไม่สงบเกิดจากอาการเพ้อ(delirium)หรือโรคทางกายอื่นๆ แพทย์ควรทำ�การรักษาสาเหตุก่อ โรคเป็นลำ�ดับแรกแทนที่จะให้เพียงแค่ยารักษาโรคจิตหรือยา benzodiazepines เท่านั้น [West J Emerg Med. 2012;13(1):26–34.

การประชุมร่วมของสมาคมภาวะฉุกเฉินทางจิตเวชของประเทศอเมริกาในโครงการ BETA Psychopharmacology เกี่ยวกับเรื่อง……จิตเภสัชวิทยาของภาวะกายใจไม่สงบ

ภาวะกายใจไม่สงบ(agitation)พบบ่อยทั้งในภาวะฉุกเฉินทางอายุรกรรมและจิตเวช การรักษาพยาบาลได้อย่าง เหมาะสมในกรณีดังกล่าวถือเป็นสมรรถนะหลักอย่างหนึ่งของแพทย์เวชศาสตร์ฉุกเฉิน ในบทความนี้ผู้นิพนธ์ ได้รวบรวมการใช้ยารักษาโรคจิตในกลุ่ม first-generation second-generation และยา benzodiazepines เพื่อใช้ ในการรักษาภาวะกายใจไม่สงบ(agitation)ชนิดเฉียบพลัน รวมทั้งนำ�เสนอแนวทางจำ�เพาะในการรักษาภาวะกาย ใจไม่สงบ(agitation)ที่สัมพันธ์กับภาวะต่างๆได้แก่ การได้รับสารพิษ ภาวะจิตเภท อาการเพ้อ(delirium) รวมทั้ง เกิดขึ้นโดยไม่ทราบสาเหตุ การใช้ยาเพื่อรักษาภาวะกายใจไม่สงบควรพิจารณาตามสาเหตุก่อโรคที่เป็นไปได้มาก ที่สุด ถ้าภาวะกายใจไม่สงบเกิดจากอาการเพ้อ(delirium)หรือโรคทางกายอื่นๆ แพทย์ควรทำ�การรักษาสาเหตุก่อ โรคเป็นลำ�ดับแรกแทนที่จะให้เพียงแค่ยารักษาโรคจิตหรือยา benzodiazepines เท่านั้น [West J Emerg Med. 2012;13(1):26–34.

Cross-transmission in the dental office: Does this make you ill?

Purpose of Review: Recently, numerous scientific publications were published which shed new light on the possible risks of infection for dental healthcare workers and their patients. This review aimed to provide the latest insights in the relative risks of transmission of (pathogenic) micro-organisms in the dental office. Recent Findings: Of all different routes of micro-organism transmission during or immediately after dental treatment (via direct contact/via blood-blood contact/via dental unit water and aerosols), evidence of transmission is available. However, the recent results put the risks in perspective; infections related to the dental office are most likely when infection control measures are not followed meticulously. Summary: The risk for transmission of pathogens in a dental office resulting in an infectious disease is still unknown; it seems to be limited in developed countries but it cannot be considered negligible. Therefore, maintaining high standards of infection preventive measures is of high importance for dental healthcare workers to avoid infectious diseases due to cross-contamination