Received: 10 April 2020 Revised: 13 May 2020 Accepted: 15 May 2020

DOI: 10.1002/emp2.12138

REVIEW ARTICLE
Injury Prevention

Improving the management of acutely agitated patients in the

emergency department through implementation of Project
BETA (Best Practices in the Evaluation and Treatment of
Agitation)

Lynn P. Roppolo MD1 David W. Morris PhD2 Fuad Khan MD, MBA2
Rohini Downs PharmD3 Jeffery Metzger MD1 Tiffany Carder RN, MSN4
Ambrose H. Wong MD, MSEd5 Michael P. Wilson MD, PhD6

1
University of Texas Southwestern Medical
Center, Department of Emergency Medicine, Abstract
Dallas, Texas, USA
Agitated patients presenting to the emergency department (ED) can escalate to
2
University of Texas Southwestern Medical
aggressive and violent behaviors with the potential for injury to themselves, ED staff,
Center, Department of Psychiatry, Dallas,
Texas, USA and others. Agitation is a nonspecific symptom that may be caused by or result in a
3
Parkland Memorial Hospital, Pharmacy life-threatening condition. Project BETA (Best Practices in the Evaluation and Treat-
Services, Dallas, Texas, USA
ment of Agitation) is a compilation of the best evidence and consensus recommenda-
4
Parkland Memorial Hospital, Emergency
Services Department, Dallas, Texas, USA tions developed by emergency medicine and psychiatry experts in behavioral emergen-
5
Yale School of Medicine, Department of cies to improve our approach to the acutely agitated patient. These recommendations
Emergency Medicine, New Haven, focus on verbal de-escalation as a first-line treatment for agitation; pharmacother-
Connecticut, USA
6
apy that treats the most likely etiology of the agitation; appropriate psychiatric eval-
University of Arkansas for Medical Sciences,
Department of Emergency Medicine, Little uation and treatment of associated medical conditions; and minimization of physical
Rock, Arkansas, USA
restraint/seclusion. Implementation of Project BETA in the ED can improve our abil-
Correspondence ity to manage a patient’s agitation and reduce the number of physical assaults on ED
Lynn Roppolo, MD, Professor, University of staff. This article summarizes the BETA guidelines and recent supporting literature for
Texas Southwestern, Department of Emer-
gency Medicine, 5323 Harry Hines Blvd., managing the acutely agitated patient in the ED followed by a discussion of how a large
Dallas, TX 75390-8579, USA. county hospital integrated these recommendations into daily practice.
Email: [email protected]

KEYWORDS
Funding and support: By JACEP Open policy,
agitation, physical assault, Project BETA, workplace violence
all authors are required to disclose any and all
commercial, financial, and other relationships
in any way related to the subject of this article
as per ICMJE conflict of interest guidelines (see
www.icmje.org). The authors have stated that
no such relationships exist.

Supervising Editor: Marna Rayl Greenberg, DO, MPH.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

JACEP Open 2020;1–10. wileyonlinelibrary.com/journal/emp2 1

2 ROPPOLO ET AL .

1 OVERVIEW AND OBJECTIVES TA B L E 1 Life-threatening causes for acute agitation in the

emergency department4,14,17,18
The emergency department is one of the most vulnerable hospital Condition
environments for workplace violence due to the high percentage of
Trauma Burns
acutely agitated patients who have the potential to escalate into acts
Head injury
of violence such as verbal or physical assaults on ED staff.1–8 A recent
Infection Syphilis
national poll in 2018 by the American College of Emergency Physi-
Meningitis, encephalitis
cians (ACEP) of >3500 emergency physicians reported that nearly half
had been physically assaulted while at work, with 60% occurring within Sepsis from other infections

the past year.8 A survey of 119 emergency medicine residents in 2016 Toxicologic Adverse drug reaction (including serotonin
syndrome, neuroleptic malignant
reported that 66% had been physically assaulted by patients and only
syndrome, and steroid-induced psychosis)
16.8% confirmed prior training in violence prevention.7
Overdose or intoxication
Until recently, these violent behaviors by agitated patients in the ED
were considered to be “part of the job” with seemingly one solution—to Sedative-hypnotic agent withdrawal

“restrain and medicate,” referring to the simultaneous use of physical Respiratory Hypoxia
restraints and chemical sedatives to control the patient’s behavior. In Hypercarbia
2012, the American Association of Emergency Psychiatry (AAEP) pub- Cardiovascular Shock
lished Project BETA (Best Practices in the Evaluation and Treatment Hypertensive encephalopathy
of Agitation).9–14 These guidelines detail methods for a noncoercive,
Thermoregulation Hypothermia
collaborative approach to managing acutely agitated patients based on
Hyperthermia
both the best available evidence and expert consensus recommenda-
Metabolic/endocrine Acidosis
tions. The purpose of this article is to review these guidelines and dis-
Hyper- or hypo-glycemia
cuss their implementation in the ED of a large county hospital.
Electrolyte abnormalities
Hyper- or hypo-cortisolism
2 OVERVIEW OF BETA GUIDELINES
Hepatic or uremic encephalopathy
Nutritional deficiency (eg, Wernicke’s
2.1 General approach
encephalopathy)
Thyroid disorders (eg, thyroid storm,
Project BETA was an interdisciplinary effort in 2012 led by the AAEP
myxedema coma)
that brought together experts in psychiatry, emergency medicine, nurs-
Nervous system Stroke
ing, psychology, and social work.9 The 5 workgroups articulated the
Tumor
following principles: verbal de-escalation as a first-line treatment for
Seizure
agitation; pharmacotherapy that treats the most likely etiology of
the agitation; appropriate psychiatric evaluation; appropriate treat- Vasculitis

ment of associated medical conditions; and minimization of physical Hemorrhage

restraint/seclusion.9-14 Given that most physical assaults occur during Hydrocephalus
the containment process, this approach can avert some violent acts Dementia or other chronic cognitive
against ED staff.15 The critical steps discussed in Project BETA are impairment
briefly summarized below. Psychiatric Psychosis
Schizophrenia

2.2 De-escalation Paranoid delusions

Personality disorder
De-escalation can be defined as a combination of both verbal and non- Adapted from Gottlieb et al18 with permission.
verbal strategies intended to assist the patient with calming down to
cooperate with their ED evaluation and treatment.12 Patients who are
able to make eye contact and engage in any form of conversation are 2.3 Medical evaluation
more likely able to be de-escalated. De-escalation is a powerful tool
to reduce a patient’s agitation, build trust with caregivers and miti- The medical evaluation begins during the initial assessment and eval-
gate violent acts but requires an empathetic attitude, patience, and sin- uates the patient for “red flags” (eg, abnormal vital signs, trauma,
cere interest in helping the agitated patient regardless of their history and abnormal neurologic exam) concerning life-threatening issues that
or clinical presentation. Prompt de-escalation tactics may effectively need immediate attention. A more thorough evaluation is performed
reduce aggressive behavior16 and are described elsewhere.12 once the patient is calmer and is safe to do so. Collateral information
ROPPOLO ET AL . 3

FIGURE 1 Violence/agitation severity leveling and initial course of action. IM, intra-muscular injection

from out-of-hospital providers, bystanders, or significant others are 2.5 Pharmacotherapy

invaluable to determining the etiology of the patient’s agitation. The
most common life-threatening etiologies for acute agitation are listed Although multiple pharmacological options have been proposed for the
in Table 1.17,18 Agitation severity and violence risk must also be deter- treatment of agitation, some general principles guide therapy. Medi-
mined ideally with one of the validated tools available to quantify this cations may help agitation symptoms if non-pharmacologic measures
assessment.19,20 The patient’s response to de-escalation and level of are not successful,11 Medications are intended to “calm” the patient
agitation will determine the next step (Figure 1). without over sedation,28 which is a significant concern in higher risk
Diagnostic studies may be indicated to evaluate for medical causes patients (eg, elderly).29 Thus, the lowest possible dose is recommended
of the patient’s agitation or sequelae of the patient’s agitated state in these individuals.29,30
such as dehydration, rhabdomyolysis, renal insufficiency, and respi- When possible, the patient needs to be involved in deciding
ratory compromise (Table 2). A medical etiology must also becon- the type and route of administration.11 Oral medications are less
sidered in patients with known psychiatric disease but whose pre- expensive, more humane, and usually as effective as intramuscular
sentation is inconsistent with prior psychiatric presentations, are medications.31,32 The oral route is preferred over the intramuscular
older than 45 years old with no previous psychiatry history, or are route if the patient can cooperate and tolerate their administration.
immunocompromised.14,21,22 Sometimes offering the patient food or other supportive measure can
facilitate their cooperation with taking medication.
Medications are necessary whenever physical restraint of the
2.4 Psychiatric evaluation patient is required to prevent injuries and complications associ-
ated with resisting restraint.33 Sedating a patient requiring physical
The focus of the initial psychiatric evaluation is not to make a defini- restraint may also reduce the negative consequences in wellbeing
tive psychiatric diagnosis but to assist in determining the likely cause reported by individuals who have been physically restrained due to
of the patient’s agitation in order to guide preliminary interventions.13 their sedative and sometimes amnestic effects.34
A complete psychiatric evaluation can be obtained if indicated once The medications most commonly used in the ED for acute agitation
the patient is calm but is beyond the scope of Project BETA. The pres- are antipsychotics and benzodiazepines. Ketamine was recently added
ence of psychotic symptoms (eg, hallucinations, delusions, disorganized to this list for severely agitated patients.35-37 The most likely etiology
thoughts) will influence medication choices if required for agitation for the patient’s agitation influences medication choices (Figure 2).11
symptoms. In general, antipsychotics are used for patients with psychosis and
4 ROPPOLO ET AL .

TA B L E 2 Diagnostic studies that may be indicated in the evaluation of the agitated patient

Name of test Indication or example pathology causing or resulting from agitation

Point-of-care glucose Hyperglycemia or hypoglycemia; obtain immediately on anyone with an alteration in mental status
Complete blood count (CBC) Anemia, leukemia, infection, low or high platelets
Basic metabolic profile including Electrolyte abnormalities and renal function, normal or anion gap acidosis, dehydration
calcium, magnesium and
phosphorus
Liver function tests including Hepato-biliary disease including liver failure, malnutrition (low albumin)
albumin
Lipase Pancreatitis
Ammonia Hepatic encephalopathy23
Troponin Cardiac structural abnormality
Creatine phosphokinase Rhabdomyolysis, myopathy, other muscle damage or inflammation
Lactate dehydrogenase Cell damage or destruction; in setting of low platelets, concerning for thrombotic thrombocytopenic purpura
(TTP)
Thyroid stimulating hormone Hypo or hyperthyroidism
Lactate Tissue hypoxia; sepsis24
Urine toxicology screen Evaluate for ingestion, explain alteration in mental status or association with persistent tachycardia or severe
hypertension. Many limitations with false–positive and false–negative results25
Acetaminophen level To evaluate for overdose, a 4-h level of 140–150 µg/mL at 4 h requires treatment with N-acetylcysteine (NAC).26
Salicylate level To evaluate for overdose, severity depends on clinical presentation, severity of acidosis and plasma salicylate
concentration that may not be reliable and needs repeating27
Urinalysis Infection, hydration status, ketosis
Pregnancy test For all women of reproductive age
Blood culture To evaluate for infection in sepsis workup
Urine culture To evaluate for infection in sepsis workup
Protime with INR To evaluate for coagulopathy or screening for lumbar puncture
Partial thromboplastin time To evaluate for coagulopathy or screening for lumbar puncture
Cerebrospinal fluid Encephalitis or meningitis, syphilis, cerebritis
Electrocardiogram (ECG) To evaluate for changes associated with electrolyte abnormalities, overdose or drug side effects (eg, QTc
prolongation), cardiac disease
Head CT scan To evaluate for mass lesion, bleed, stroke, large ventricles

benzodiazepines are added if agitation symptoms persist after the ini- 2.6 Restraint and seclusion
tial dose of antipsychotic. Second generation antipsychotics (SGA) have
less extrapyramidal symptoms (EPS) than the first generation antipsy- Project BETA strongly opposes the practice of restraint and seclu-
chotics. Benzodiazepines or antihistamines are often co-administered sion. Seclusion is less commonly used in the ED setting.10 Although
with first generation antipsychotics to counteract these effects. restraints are thought to be an effective method to temporarily halt
Benzodiazepines are given for agitation symptoms due to intoxi- violent behaviors, restraints carry an elevated risk of injury to patients
cation, especially stimulants but antipsychotics are preferred for and staff,15,33,53 are experienced as coercion or aggression, and can
intoxications due to central nervous system depressants such as lead to psychological trauma.34 For these reasons, the Center for
alcohol. Patients with agitation due to alcohol or benzodiazepine with- Medicare & Medicaid Services (CMS) established guidelines regard-
drawal are treated with benzodiazepines. Benzodiazepines are also ing restraint and seclusion for healthcare professionals emphasiz-
recommended for patients with undifferentiated agitation; however, ing that patients cannot be restrained only for refusal of care or as
antipsychotics may help if psychotic symptoms are present. Low-dose punishment.54
antipsychotics are also the drug of choice in agitated patients with The patients’ privacy and dignity need to be maintained during
delirium if symptoms persist despite attempts to treat the underlying restraint application.55 If possible, five trained individuals need to
etiology and nonpharmacological interventions are insufficient.11 apply the physical restraints with one person at each extremity and
Table 3 summarizes medications most commonly used for agitation in one person at the head of the bed, being careful to avoid bodily
the ED. injury due to excessive use of force or compromise the patient’s
ROPPOLO ET AL . 5

FIGURE 2 Pharmacology algorithm: medication recommendations depend on most likely etiology of the patient’s agitation11,56

3 IMPLEMENTATION OF THE BETA

GUIDELINES: THE PARKLAND EXPERIENCE

Parkland Hospital is a busy county hospital with an annual ED volume

of over 240,000 patient visits and a large emergency medicine resi-
dency program. In 2016, as part of a quality improvement (QI) initia-
tive due to an influx of physical assaults by patients on our residents in
the Parkland ED, an agitation order set in the electronic medical record
was created and an educational curriculum was developed based on
the BETA guidelines. The order set includes all physician orders typi-
cally needed for agitated patients (Table 4) and was created by a multi-
disciplinary team, composed of ED administrators, nursing, emergency
and psychiatry physicians, pharmacists, and police. The objective of the
agitation order set was to make it easier for ED providers to adhere
to the BETA recommendations, because order sets have demonstrated
effectiveness in regards to improving compliance with guidelines.60
F I G U R E 3 Correct application of restraints for severely agitated
The agitation educational curriculum includes verbal de-escalation and
patients. Original image by Skylar Burchatz with permission
self-defense training for incoming interns, as well as annual teaching
of the BETA guidelines and Parkland’s agitation protocol through lec-
tures and simulation. An unpublished survey just prior to implemen-
ability to breathe.56,57,58 Once the patient is calmer, they can be placed tation found that 28% of the 50 emergency medicine residents who
in a supine position with the head of the bed elevated and extremity responded had been physically assaulted by an ED patient during resi-
restraints tethered to the side of the bed and not the side rails prefer- dency.
ably with one arm upward and the other downward. The legs need to Several new policies and protocols were developed concurrently by
be tied to the opposite side of the bed to minimize the patient’s abil- the Parkland ED administration to improve safety and the care pro-
ity to kick ED staff (see Figure 3).58,59 All care providers need to wear vided to agitated patients. These and some pre-existing related prac-
appropriate personal protective equipment especially if the patient is tices are summarized below that further support the BETA initiatives.
spitting or trying to bite ED staff. If this occurs, also consider placing
an oxygen mask over the face if institutional laws do not restrict this 1. Parkland’s “zero tolerance” for violence policy is posted at hospital
practice. entrances.
6 ROPPOLO ET AL .

TA B L E 3 Pharmacology for the agitated patients11,35,38–52

Generic Trade Time of

Category name name Dose onset(min) Comments
First generation Haloperidol Haldol Mild: 2.5 mg PO 30 ∙ Highest risk of EPS; administer with benztropine,
antipsychotic Moderate: 5 mg PO 30 diphenhydramine, lorazepam, OR promethazine can decrease
Severe: 5 mg IM 30 risk and need for repeated doses. Avoid 3 drug therapy.
∙ Increased risk for QTc prolongation with IV route.
∙ May lower seizure threshold
∙ May repeat in 0.5–4 h. MAX: 30 mg/day

Droperidol Inapsine Severe: 5 mg IM or IV 15 ∙ Increased risk for EPS and QTc prolongation
∙ Administer with 5 mg of midazolam. MAX: 10–20 mg/day

Second generation Olanzapine Zyprexa Mild: 5 mg ODT ≤60 ∙ Avoid concomitantly use of benzodiazepines within 1 h
antipsychotic Moderate: 5–10 mg ≤60 ∙ MAX: 20 mg/day
ODT 15–45
Severe: 10 mg IM
Risperidone Risperdal Mild: 1 mg ODT ≤60 ∙ Works best in patients with undifferentiated agitation or
Moderate: 2 mg ODT ≤60 substance use related agitation (except for CNS depressant
intoxication).
∙ Highest risk for EPS of SGAs. Can cause orthostatic
hypotension.
∙ May repeat every 4–6 h. MAX not established but caution
above 10 mg/d.

Ziprasidone Geodon Severe: 10–20 mg IM 15–30 ∙ Highest risk of QTc prolongation of SGA, likely exceeds
haloperidol. Avoid use in patients with cardiac disease or
pre-existing QTc prolongation.
∙ Needs to be reconstituted
∙ May repeat dose in 4 hours. MAX: 40 mg/d

Benzodiazepines Lorazepam Ativan Mild: 2 mg PO 20–30 ∙ Slowest onset and longest duration of all benzos.
Midazolam Versed Mild: 13–18 ∙ Used for undifferentiated agitation but use with caution in
Moderate: 5 mg IM or 15 (IM) patients with CNS depression (eg, ethanol intoxication).
2.5 mg IV 5 (IV) ∙ For severe agitation, can give midazolam 5 mg IM with
Severe: 10 mg IM or 15 (IM) haloperidol or droperidol 5 mg IM.
5 mg IV 5 (IV)
Dissociate Ketamine Ketalar 1–2 mg/kg IV or up to 1–2 (IV); 3 ∙ Can cause emergence reaction, bronchorrhea and
anesthetic 5 mg/kg IM (IM) laryngospasm (rare). May increase intubation rate.
∙ Typically used for severely agitated patients such as excited
delirium. Can increase HR, CO, BP

Abbreviations: BP, blood pressure; CO, cardiac output; EPS, extrapyramidal symptoms; HR, heart rate; IM, intramuscular; IV, intravenous; ODT, orally disinte-
grating tablets.

2. All ED nurses receive training in de-escalation and self-defense 4. Cameras are located throughout the ED and worn by police to
training. record events.
3. The hospital has its own police force with officers at all public 5. Nurses in triage screen patients with the violence screening tool
entrances to the ED where they screen all patients and visitors with STAMP (Staring and eye contact, Tone and volume of voice, Anxi-
metal detectors. One of the officers on duty is designated to be ety, Mumbling, and Pacing)61 and document this in the electronic
the LIFE (Law Enforcement Intervention for Environmental/Patient medical record where it is easily visible on the patient tracking
Safety) officer who has advanced training in communication and de- board. A special wrist band is placed on the patient, and a sign is
escalation skills. This specially trained officer may familiarize them- placed on their doorway to alert all healthcare workers of the vio-
selves to the potentially violent patient and can easily return if a lence risk. Prior history of violent behavior is also highlighted in the
patient starts to escalate. ED staff can contact the Parkland police electronic medical record.
by radio, phones, or use of a panic button located in each patient 6. Any patient who is a danger to themselves or others is typi-
care area. Parkland police aid in physical restraint when indicated, cally assigned a sitter who removes all objects from the patient’s
allowing ED staff the ability to safely medicate, evaluate, and treat room and does continuous observation, usually from the door-
the patient. way. These patients are dressed in green hospital gowns with
ROPPOLO ET AL . 7

TA B L E 4 Main components of the Parkland “agitation” orderset

Project BETA Parkland order set Detailed description

De-escalation Calming technique reminders ∙ Respect personal space but ensure safety
∙ Use appropriate language (eg, soft voice, slow movements, eye contact, do not
provoke, be concise)
∙ Identify wants and listen closely to what patient is saying
∙ Agree to disagree
∙ Set clear limits and explain what will happen in ED
∙ Offer choices and optimism (eg, food, drink, blanket)
∙ Debrief patient and staff

Triage Behavioral Activity Rating Scale ∙ BARS 5 = mild agitation (eg, pacing, restless, intrusive behavior, easily annoyed or
(BARS)19 angered, confused, physically distressed but is redirectable)
∙ BARS 6 = moderate agitation (eg, signs of aggression but no violent, continuously
pacing/restless, confused/unable to cooperate, needs continuous redirection )
∙ BARS 7 = severe agitation (eg, striking staff or other patients, harming or
repeatedly threatening to harm self or others, violence, destroying property, not
redirectable and not responding to de-escalation

Medical evaluation Diagnostic testing ∙ ECG

∙ Laboratory studies
∙ Imaging (eg, CT head)

Psychiatric evaluation Psychiatry contact information Direct phone number for Parkland emergency psychiatry attending listed
Pharmacotherapy ∙ Medications for agitation ∙ Medications for agitation due to a psychiatric etiology
∙ Includes post-sedation 1. Mild: ORAL haloperidol/lorazepam, haloperidol/diphenhydramine, risperidone,
monitoring and alerts included OR olanzapine
for elderly dosing and when to 2. Moderate: ORAL haloperidol/lorazepam, haloperidol/diphenhydramine, OR
avoid antipsychotic olanzapine
administration 3. Severe: IM haloperidol/lorazepam, haloperidol/diphenhydramine, OR
olanzapine
∙ Medications for undifferentiated agitation
1. Mild: ORAL lorazepam
2. Moderate: IV or IM midazolam
3. Severe: IM haloperidol/midazolam OR IM/IV midazolam

Restraint Restraint orders Specific order sets for either violent or non-violent restraints

Abbreviations: BARS, Behavioral Activity Rating Scale; Project BETA, Best Practices in the Evaluation and Treatment of Agitation; IV, intravenous; IM intra-
muscular.

yellow socks for easy identification and their belongings are distance for medical concerns requiring immediate attention. There is
secured. The observers carry radios to rapidly call for help. Offi- a low threshold to call for security assistance early, even for milder
cers remain in the room for patients in jail or have a high violence forms of agitation due to the potential for escalation. One study found
risk. that health care workers who had experienced non-physical violence
7. There is an ED Violence Prevention Response Team, composed of (eg, verbal threats) were 7.17 times more likely to experience physical
ED leadership, nurses, and police officers, who round on potentially violence.62
violent patients and are called to the bedside during any escala- Severely agitated patients are triaged to the critical care area of
tions. After an event, the Violence Prevention Response Team does the ED where there are computers in each room. The physician’s role
a debriefing to prevent recurrences. All events are tracked in the is to quickly enter orders and be the team leader regarding how the
Parkland safety system for aggregate analysis. If a physical assault patient is managed. If the patient requires forced medication and phys-
occurs, the victim can press charges. ical restraint, the officers safely restrain the patient and the nurse
8. The SPARKS program (“Supporting PARKland Staff”) was created administers the intramuscular injection once safe to do so.
for post incident support, and is a team specially trained to pro- At the time of this work, 18 months after implementation, there
vide confidential support for staff victims. These employees have have been violent physical assaults by patients on 5 of our 66 emer-
the option to take 3 days of workplace violence leave. gency medicine residents in the Parkland ED, only one of these
occurred during the last 12 months. Fortunately, there were no signif-
In general, agitated patients are promptly seen by ED providers icant injuries and all but one could have been prevented if the BETA
who attempt de-escalation while evaluating the patient from a safe guidelines were strictly followed.
8 ROPPOLO ET AL .

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