Step 2: When Negotiation Has Failed—Simultaneously Assess and Act

If negotiation has failed and the patient remains agitated, it is unlikely that you will get a great deal of information from the patient about why they are agitated. The question, “Excuse me sir, can you please stop throwing your feces at me so that I can ask you a few questions?” is unlikely to get anyone to stop throwing feces at you.

Since the patient is likely to be in the beginning stages of the medical work up, the medical chart is unlikely to be terribly helpful in elucidating the cause of delirium. Although friends, relatives, or a physician with whom the patient has an ongoing relationship may be crucial in determining the etiology of the agitation—it is reasonable to expect that none of these people will be available in the amount of time that you will need to act.

Non-Pharmacologic Interventions

The first recommended action is to consider the resources available to help the patient without any pharmacologic intervention.

  • ? Do es the hospital have one-to-one observation available (sometimes called constant observation or sitters)? Can the patient remain without medication if someone is at their bedside constantly redirecting them and giving them instructions?
  • ? Is there is an area in the ED that has less commotion or that will be less stimulating to the agitated patient?
  • ? Can the patient be moved to an area where there is less potential for patient self-harm or harm to others? Is there a room in the ED that simply has a bed on the floor with nothing potentially dangerous suspended on the walls?
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