title: Variation in the management of hypothetical cases of acute agitation in Australasian emergency departments.
abstract: OBJECTIVE
  To describe the prescribing practice of emergency medicine clinicians in the management of highly agitated patients and to identify perceived barriers to management and the gaps in training.
  
  
  METHODS
  We undertook an anonymous cross-sectional mail survey of the Australasian College for Emergency Medicine (ACEM) members (fellows and advanced trainees) between June and September 2009. A questionnaire including a case vignette of a hypothetical patient and three clinical scenarios was employed to ascertain prescribing practice and assess perceived barriers to management, confidence and the perceived usefulness of existing and future Clinical Practice Guidelines (CPGs).
  
  
  RESULTS
  All 2052 ACEM members were surveyed. However, seven had incorrect postal addresses and could not be reached. Of the remaining 2045, 786/2052 (38.3%, 95% CI 36.2-40.5) responses were received. Of the 786 respondents, 783 were practicing clinicians. If monotherapy was chosen, 622/783 (79.4%, 95% CI 76.4-82.2) of respondents preferred midazolam to manage the common scenario where no history was available, followed by haloperidol 45/783 (5.8%, 95% CI 4.3-7.7) and olanzapine 38/783 (4.9%, 95% CI 3.5-6.7). Most respondents 500/783 (63.9%, 95% CI 60.4-67.2) would also administer another sedative (combination therapy). Important perceived barriers to agitation management included lack of both training (352/783 [45.0%, 95% CI 41.4-48.5]) and a national CPG (313/783 [40.0%, 95% CI 36.5-43.5]). Respondents were generally confident in all aspects of management, although relatively fewer trainees were confident in determining dosing. Institutional CPGs were considered most useful for 415/783 (53.0%, 95% CI 49.4-56.5) respondents. If an ACEM-endorsed CPG were to be developed in the future, 634/783 (81.0%, 95% CI 78.0-83.6) respondents would consider this useful.
  
  
  CONCLUSIONS
  There is considerable variation in the management of hypothetical cases of acute agitation in Australasian EDs. Benzodiazepines and antipsychotics, either alone or in combination, are commonly used. An ACEM-endorsed, Australasian CPG was perceived as useful.
authors.affiliation: Department of Pharmacy Practice, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia.
authors.forename: Esther W
authors.initials: EW
authors.lastname: Chan
authors.forename: David McD
authors.initials: DM
authors.lastname: Taylor
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Knott
authors.forename: David C M
authors.initials: DC
authors.lastname: Kong
mesh_terms: D000208:Acute Disease; D014150:Antipsychotic Agents / Q000627:therapeutic use; D044362:Australasia; D001569:Benzodiazepines / Q000627:therapeutic use; D002983:Clinical Competence / Q000706:statistics & numerical data; D003131:Combined Modality Therapy / Q000523:psychology; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004333:Drug Administration Routes; D004334:Drug Administration Schedule; D004635:Emergency Medicine / Q000458:organization & administration / Q000592:standards*; D004638:Emergency Treatment / Q000379:methods*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007396:Internship and Residency / Q000706:statistics & numerical data; D010820:Physicians / Q000523:psychology* / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data / Q000639:trends; D011365:Professional Practice Location; D011595:Psychomotor Agitation / Q000188:drug therapy / Q000517:prevention & control*; D011795:Surveys and Questionnaires
chemical_list: D014150:Antipsychotic Agents; D006993:Hypnotics and Sedatives; D001569:Benzodiazepines