Managing Acute Behavioural Disturbances in the Emergency Department Using the Environment, Policies and Practices: A Systematic Review

Abstract

IntroductionEffective strategies for managing acute behavioural disturbances (ABDs) within emergency departments (EDs) are needed given their rising occurrence and negative impact on safety, psychological wellbeing, and staff turnover. Non-pharmacological interventions for ABD management generally fall into four categories: environmental modifications; policies; practice changes; and education. Our objective was to systematically review the efficacy of strategies for ABD management within EDs that involved changes to environment, architecture, policy and practice.MethodsWe performed systematic searches of CINAHL Plus with Full Text, PsycINFO, MEDLINE, and EMBASE, as well as reference lists of relevant review articles to identify relevant studies published between January 1985 – April 2016. We included studies written in English, which reported management of behavioural disturbances in adults associated with the ED through the use of environmental modifiers (including seclusion, restraint, specialised rooms, architectural changes), policy, and practice-based interventions excepting education-only interventions. Efficacy outcomes of interest included incidence, severity, and duration of ABD, incidence of injuries, staff absenteeism, restraint use, restraint duration, and staff and patient perceptions. Two reviewers independently screened titles and abstracts, and assessed the relevancy and eligibility of studies based on full-text articles. Two authors independently appraised included studies. A narrative synthesis of findings was undertaken.ResultsStudies reporting interventions for managing ABDs within the ED are limited in number and quality. The level of evidence for efficacy is low, requiring caution in conclusions. While there is preliminary evidence for environmental change in the form of specialised behavioural rooms, security upgrades and ED modifications, these are not supported by evidence from controlled studies. Many of these “common sense” environmental changes recommended in many guidelines have been widely implemented in EDs.ConclusionThere is an unambiguous gap in the literature regarding the efficacy of interventions for ABD management in EDs involving environmental, policy or practice-based changes. With growing demand on EDs, and with increasing numbers of ABDs, identification of robust evidence-based interventions for safe and effective ABD management is vital.

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

“…Our recent systematic review of any literature on chemical restraint published since 1996 identified 33 potentially relevant systematic reviews (SRs) of primary studies (Muir‐Cochrane et al ). Only nine SRs included primary papers, which all specifically noted that medications had been administered without consent (Aguilera‐Serrano et al ; Goulet et al ; Jarrett et al ; Laiho et al ; Luciano et al ; Newton‐Howes & Mullen ; Steinert et al ; Tingleff et al ; Weiland et al ). None of these SRs reported on the effectiveness of medications.…”

Overview of “Systematic Reviews” of the Built Environment’s Effects on Mental Health

“…After removing duplicates, 321 were manually screened, and 286 records were excluded for title and abstract. We reviewed the full text of 35 studies, 24 of which were excluded [11,12,14,18,[23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. Finally, eleven SRs were included in the narrative synthesis ( Figure 1).…”

“…Only one of the included systematic reviews performed a metaanalysis [44], heterogeneity due to the design of primary studies, weak methodological rigor, and the lack of standardized tools that assess mental health, and built environments are the main drawbacks reported by the others SRs. Full-text articles excluded, with reasons (n = 22) Did not meet study design (n = 13) [12], [14], [18], [23], [25], [26], [28]- [31], [37], [40] [24] Did not meet study intervention (n = 6) [32], [33], [35], [36], [38], [39] Did not meet study outcome (n = 3) [11], [27], [34] (i) e research looking at the role of the built environment on mental health is relatively new, and causal pathways connecting both constructs are just starting to emerge. According to van den Bosch et al, mental health is consistently influenced directly or indirectly by multiple environmental exposures, and depressive mood may be the result of the rapid urbanization and a disconnection from our evolutionary origin and natural environments [53].…”

Utilizing compassion and collaboration to reduce violence in healthcare settings

“…wait-times, lack of privacy), negative attitudes among staff, implementing interpersonal and communication skills training for physicians and nurses, and legislative support for accompanying persons’ involvement in the care of their loved ones in healthcare facilities. Additional approaches have been suggested, although systematic reviews of the impact of potential interventions note the paucity of robust evidence to support any of those studied [ 29 , 30 ]. Clearly, more rigorous research is needed, but we discuss some interesting approaches below.…”