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Keywords:

  • aggression;
  • emergency medicine;
  • pharmaceutical preparation;
  • questionnaire;
  • violence

Abstract

Objective:  To describe the prescribing practice of emergency medicine clinicians in the management of highly agitated patients and to identify perceived barriers to management and the gaps in training.

Method:  We undertook an anonymous cross-sectional mail survey of the Australasian College for Emergency Medicine (ACEM) members (fellows and advanced trainees) between June and September 2009. A questionnaire including a case vignette of a hypothetical patient and three clinical scenarios was employed to ascertain prescribing practice and assess perceived barriers to management, confidence and the perceived usefulness of existing and future Clinical Practice Guidelines (CPGs).

Results:  All 2052 ACEM members were surveyed. However, seven had incorrect postal addresses and could not be reached. Of the remaining 2045, 786/2052 (38.3%, 95% CI 36.2–40.5) responses were received. Of the 786 respondents, 783 were practicing clinicians. If monotherapy was chosen, 622/783 (79.4%, 95% CI 76.4–82.2) of respondents preferred midazolam to manage the common scenario where no history was available, followed by haloperidol 45/783 (5.8%, 95% CI 4.3–7.7) and olanzapine 38/783 (4.9%, 95% CI 3.5–6.7). Most respondents 500/783 (63.9%, 95% CI 60.4–67.2) would also administer another sedative (combination therapy). Important perceived barriers to agitation management included lack of both training (352/783 [45.0%, 95% CI 41.4–48.5]) and a national CPG (313/783 [40.0%, 95% CI 36.5–43.5]). Respondents were generally confident in all aspects of management, although relatively fewer trainees were confident in determining dosing. Institutional CPGs were considered most useful for 415/783 (53.0%, 95% CI 49.4–56.5) respondents. If an ACEM-endorsed CPG were to be developed in the future, 634/783 (81.0%, 95% CI 78.0–83.6) respondents would consider this useful.

Conclusion:  There is considerable variation in the management of hypothetical cases of acute agitation in Australasian EDs. Benzodiazepines and antipsychotics, either alone or in combination, are commonly used. An ACEM-endorsed, Australasian CPG was perceived as useful.