Emergency Department Agitation Code Response Team Reduces Use of Physical Restraints

By Christopher Cheney

A team-based approach to responding to agitated patients in the Emergency Department (ED) setting can result in a significant decrease in the utilization of physical restraints, a recent journal article says.

Agitation is defined as excessive psychomotor activity that causes violent and aggressive behavior. It has been estimated that 1.7 million instances of agitated patients occur in acute care settings every year. Although use of physical restraints for agitated patients is common, earlier research has associated them with several poor outcomes, including psychological harm, physical trauma, respiratory depression, and death.

The recent journal article, which was published by Annals of Emergency Medicine, describes the design and implementation of an agitation code response team at Yale-New Haven Hospital in New Haven, Connecticut.

The agitation code response team was developed in three phases over a five-year period, resulting in a 27.3% decline in the physical restraint rate.

“With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a five-year period. Results suggest that investment in organizational change along with interprofessional collaboration during the management of agitated patients in the ED can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients,” the co-authors of the journal article wrote.

A multidisciplinary agitation management task force was formed to oversee the design and implementation of the initiative. Members of the task force included emergency medicine physicians, nursing managers, protective services lieutenants, and ad-hoc staff members from administrative leadership, pharmacy, and patient relations.

5-part agitation code response team protocol

The agitation code response team was modeled on response teams for other acute conditions such as stroke. The protocol for the agitation code response team features five elements.

1. Activation: “Any licensed nurse or clinical provider could initiate overhead activation of the code response team if (1) patient agitation required more than one staff member to manage, (2) if there was an immediate safety risk identified related to agitation, or (3) when a notification was received from prehospital services regarding an incoming patient who may be a potential safety risk due to agitation, with approval by a senior nurse on shift,” the journal article’s co-authors wrote.

2. Roles and responsibilities: There are three essential members of the agitation code response team.

  • A senior physician or advanced practice provider serves as the team lead. This team member performs the primary patient assessment, attempts de-escalation with the patient, and assesses whether the patient requires chemical sedation and/or physical restraint.
  • A primary nurse monitors the patient’s status, administers care, and documents in the health record.
  • A lead protective services officer monitors the physical safety of the patient and staff, stabilizes patient extremities if physical restraints are required, and defers to the team lead before any physical maneuvers are made on the patient, unless officers perceive an immediate risk to staff.

3. Process and workflow: “The process and workflow of the code response team provided guidelines for transporting the agitated patient immediately into one of the resuscitation bays if possible and recommendations to attempt initial de-escalation for every patient but apply physical restraints and chemical sedation if immediate danger to self or others was present. It also described processes related to written and verbal handoffs between the code team and staff receiving the patient in other care areas once the initial response ended and it was safe to transition care,” the journal article’s co-authors wrote.

4. Health record support: The agitation code response team protocol includes “standardized phrases for documenting decision-making and clinical course in the provider notes, nursing flowsheets and narrators, and order sets for sedation and restraint,” the journal article’s co-authors wrote.

5. Continuous quality improvement: “We standardized a continuous quality improvement process for the intervention with (1) regular audits and observations of responses by task force members, (2) encouragement of clinical debriefs after each response, (3) anonymous feedback from staff members through a [Quick Response] code posted in each resuscitation bay, and (4) monitoring of patient safety incident reports and charge nurse reports related to code team activations and responses. Any potential issues, areas for improvement, and sentinel cases were fed back to the task force to review and make iterative improvements during regular biweekly meetings,” the journal article’s co-authors wrote.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.