Three‑pillar agitation plan

A psychiatry resident’s three-part plan for managing agitation tracks closely with mainstream guidance: start with de-escalation and the room, not the syringe. (nih.gov) The framework mirrors Project BETA, a 2012 set of best-practice guidelines from the American Association for Emergency Psychiatry that put verbal de-escalation first, tie medication to the likely cause, and aim to minimize restraint and seclusion. (nih.gov) That order matters because agitation is a symptom, not a diagnosis. A 2024 Academy of Consultation-Liaison Psychiatry guide tells clinicians to first sort out delirium, intoxication or withdrawal, a primary psychiatric disorder, or an undetermined cause before choosing treatment. (clpsychiatry.org) The first pillar is environmental and behavioral: clear dangerous objects, reduce noise and other stimulation, keep close observation, and use calm, concise conversation that respects personal space and offers choices. (clpsychiatry.org) The second pillar is medication only if those steps fail, and the drug should match the cause. The same 2024 guide lists oral antipsychotics such as risperidone 2 milligrams or olanzapine 5 to 10 milligrams for many delirium-related cases, while benzodiazepines are reserved for alcohol or benzodiazepine withdrawal and stimulant intoxication. (clpsychiatry.org) It also tells clinicians to use the lowest effective dose in delirious patients because higher doses raise the risk of extrapyramidal side effects, the movement problems that can come with antipsychotics. (clpsychiatry.org) The third pillar is measurement: use a common scale so staff describe the same behavior the same way across shifts. The Richmond Agitation-Sedation Scale, or RASS, runs from +4 for combative to -5 for unarousable, with 0 meaning alert and calm. (sciencedirect.com) Another tool cited in agitation workflows is the Agitated Behavior Scale, or ABS, a 14-item checklist scored from 14 to 56 that was developed for patients recovering from acquired brain injury. (sralab.org) The push for structured approaches comes as hospitals report more violence around agitated patients. A 2018 American College of Emergency Physicians poll of more than 3,500 emergency physicians found nearly half had been physically assaulted at work, and 60% of those assaults had happened within the previous year. (nih.gov) Project BETA’s original publication ran in February 2012, and later reviews have kept the same core sequence: identify the cause, de-escalate first, medicate carefully, and document with objective tools. The resident’s thread packages that playbook into a format clinicians can use at the bedside. (escholarship.org)