Management of acute agitation in Australasian emergency departments: variations in practice

Abstract

INTRODUCTION: We aimed to describe current prescribing practice of emergency medicine clinicians in the management of highly agitated patients and to identify perceived barriers and gaps in training. METHODS: We undertook an anonymous cross-sectional mail survey of ACEM members between June and September, 2009. A questionnaire including a case vignette of a hypothetical patient and three clinical scenarios was employed. RESULTS: Of 2045 members surveyed 786 (38.4%) responses were received. Where no history was available, midazolam was the preferred monotherapy for 80.0% of respondents, followed by haloperidol (5.7%) and olanzapine (4.9%). Most respondents (500, 63.9%) would preferentially administer another sedative (combination therapy). The most common additional agents were haloperidol (238, 47.6%) olanzapine (100, 20.0%) and droperidol (82, 16.4%). The IV route was preferred for most drugs. The main reasons for using a combination were the differing mechanisms of action (437, 87.4%) and lower dosage requirements (289, 57.8%). Reported barriers to management included lack of both training (352, 44.9%) and national clinical guidelines (313, 40.0%). Respondents were generally confi dent in all aspects of management, though relatively fewer trainees were confi dent in determining dosing. Institutional guidelines were considered most useful for 415 (415/783, 53.0%) respondents. If an ACEM endorsed guideline were to be developed in the future, 634 (81.0%) respondents would consider this useful. CONCLUSIONS: There is considerable variation in the management of acute agitation in Australasian EDs. Benzodiazepines and antipsychotics, either alone or in combination are commonly used. An ACEM endorsed guideline is recommended.