Presentations

Abstract

Introduction:

Agitation is excessive psychomotor activity resulting in an extreme form of arousal that may be complicated by aggressive or violent behavior. Agitation has a broad differential diagnosis, but regardless of the cause, it may serve as a safety risk for both patients and healthcare workers. Of note, healthcare workers experience 50% of occupational assaults in the United States (US), and studies have shown that younger clinicians and those in the emergency, psychiatric, and geriatric settings are at highest risk of violence. Despite these statistics, medical students repeatedly report that they feel they have inadequate time dedicated to management of agitation during the course of their medical education. Verbal de-escalation is the gold standard for agitation management. However, it is difficult to teach in real clinical settings as the presentation is unpredictable, and it may be difficult to maintain patient safety while still allowing the student to make mistakes and receive feedback. Although there is a lack of high quality evidence into the effectiveness of verbal de-escalation training programs, a previous study demonstrated that students have increased confidence working with agitated patients after receiving virtual simulation training. We decided to implement in-person simulation training for de-escalation techniques after learning that many pre- clerkship medical students felt uncomfortable managing episodes of patient agitation in the weekly Eastern Virginia Medical School (EVMS) Street Health clinic. The most common causes of acute agitation in this clinic are exacerbation of a psychiatric condition (at least 35% of our patients present for management of a psychiatric condition) or acute intoxication.

Methods:

A de-escalation workshop was led by a senior psychiatry resident. Following the presentation, several unique patient encounters were acted out by senior medical students for small groups. The psychiatry resident ended the session with feedback and final discussion. Pre- and post-session surveys were anonymously administered via QR code to a REDcap link. The survey instruments used were a combination of demographic questions, a modified Perceived Stigma Questionnaire (PSQ-13) and Thackrey's Confidence in Coping and Patient Aggression 10-item Questionnaire scaled 1-11. Data was stored and analyzed using REDCap.

Results:

Fifty seven students completed the pre-session survey (51% female, 1.8% identified as gender non-conforming). Of those, 56 attendees completed the demographic survey. 35% were first year and 51% were second year medical students. 68% of the attendees were involved in an in-person free clinic. 94% had not participated in a de-escalation class in the past, and 75% would not know what to do when confronted with aggressive behaviors. On the pre-session Thackrey Confidence Scale, attendees measured comfortability working with aggressive patients at a mean of 4.84±2.68, handling psychological aggression at a mean of 3.58±2.16, and training for handling physical aggression at a mean of 3.56 ± 2.87. Forty seven students completed the post-session surveys and reported comfortability level working with aggressive patients at a mean of 6.74±1.47, handling psychological aggression at a mean of 6.59±1.69, and training for handling physical aggression at a mean of 5.81± 2.21. A mean of 10.04 ± 1.41 respondents would likely recommend this session to a friend. 58% overall rated this workshop as 'excellent' and 33% overall rated the session as 'very good'.

Conclusions:

In-person simulation training increases student comfort in working with aggressive patients and handling psychological aggression. Free responses from the post-session survey revealed that the students felt the session was helpful and recommended that other students attend the workshop. It would be reasonable to make the benefits of this verbal de- escalation training more widespread by incorporating it into the simulation-based clinical skills course provided by the school to all first and second-year medical students.