4.0 The Protocol for De-escalation and Management
The protocol for managing agitation is guided by three core goals: to ensure the immediate safety of the patient and staff, to calm the patient without resorting to excessive sedation, and to address the acute crisis while preparing for the long-term treatment of the underlying cause.
4.1 First Priority: Establishing a Safe Environment
The first priority upon identifying an agitated patient is to secure the environment. This protocol mandates two immediate actions:
- Move the patient to a calm, private room with minimal sensory stimulation.
- Remove any objects from the patient’s vicinity that could be used to cause harm to themselves or others.
4.2 Non-Pharmacological Intervention: Verbal De-escalation
Verbal de-escalation is the primary and preferred intervention technique. The goal is to build rapport and calm the patient through respectful communication. Key strategies include:
- Maintain a calm and respectful tone.
- Acknowledge the patient’s distress with empathetic language (e.g., “I can see you are very upset.”).
- Avoid potentially threatening non-verbal cues, such as loud tones, rushed speech, and prolonged direct eye contact.
- Emphasize that physical restraint is a last-resort measure, to be used only by specifically trained personnel when there is an immediate and unavoidable risk of harm, as its improper use can significantly escalate agitation.
4.3 Criteria and Application of Pharmacological Intervention
Medication must be considered only when non-pharmacological methods are insufficient or when the patient’s agitation is so severe that it poses an immediate danger to themselves or others. The goal is to achieve rapid calming while preserving the patient’s ability to communicate.
The primary classes of medication used are:
- Benzodiazepines: These are highly effective in rapidly reducing anxiety, restlessness, and muscle tension. They are a first-line choice for agitation related to substance withdrawal.
- Antipsychotics: These are particularly useful for managing agitation associated with psychotic symptoms, such as paranoia and hallucinations.
In severe and resistant cases, a combination of an antipsychotic and a benzodiazepine may be utilized to achieve safe and effective sedation.
Adherence to this tiered approach is paramount, as deviation carries significant risks for the patient, staff, and the therapeutic process.