Management of acute agitation in the accident and emergency setting: a survey of practice in Hong Kong

Abstract

BACKGROUND: Little is known about the use of sedation drugs for the management of acute agitation in Hong Kong’s Accident and Emergency Departments (AEDs), and how it compares with Australasian practice. OBJECTIVES: To determine drug preferences, clinician’s perceived confidence in management, barriers/gaps in training, and perceived usefulness of existing clinical practice guidelines (CPGs) in Hong Kong. METHOD: A validated questionnaire was used, with case vignettes typical of those presenting to AEDs with acute agitation. The questionnaire was distributed by hand to all trainees and fellows of the Hong Kong College of Emergency Medicine (HKCEM). Two reminders were sent to non-responders. RESULTS: Of 483 HKCEM members, 58.0% (95%CI 53.5–62.3) responded. For monotherapy, 46.8% (95%CI 41.0–52.6) of respondents chose haloperidol to manage the undifferentiated patient, followed by midazolam (3.9%, 95%CI 28.6–39.7) and diazepam (13.9%, 95%CI 10.4–18.5). Most respondents (83.6%, 95%CI 78.8–87.5) would not administer combination therapy. The lack of local/institutional CPGs (55.7%, 95%CI 49.9–61.4) was perceived as an important barrier. Respondents were confident in agitation management overall. Institutional guidelines were considered the most useful CPGs (66.4%, 95%CI 60.7–71.7). Most respondents (72.9%, 95% CI 67.4–77.7) perceived an HKCEM endorsed CPG as useful. CONCLUSION: The use of haloperidol and benzodiazepines as monotherapy is common in the management of acute agitation in Hong Kong’s AED. Combination therapy is less popular compared to Australasian practice. Prescribers’ choice of sedation drugs are also more conservative and less variable overall. Future work could focus on CPG development and training regarding the safe use of combination therapy.