Management of Agitation in Complex Neurobehavioral Syndromes in the General Hospital Setting: An Online Curriculum for Hospitalists

Abstract:

Background: There are few formal curricula aimed at teaching hospitalists how to manage agitation in the general medical setting.¹ Certain populations, specifically patients with acquired brain injury (ABI), dementia, and intellectual and developmental disability (IDD) are at higher risk for developing agitation with medical care outside of the setting of delirium due to pervasive cognitive barriers.^1,2 Internal medicine providers are often first-line clinicians to experience agitation and receive little formal training in treating agitation in patients with ABI, dementia, and IDD.³ These providers may benefit from online learning modules tailored towards teaching them agitation management, especially in patients with ABI, dementia, and IDD.

Methods: We offered the online course to all hospitalists at Johns Hopkins Bayview. Hospitalists were sent a recruitment email and had to complete a needs assessment survey, the modules, and then a post assessment survey. Phase two of the study will involve 1) launching the modules at two other Hopkins sites, 2) development and dissemination of vignette-based cases and a study guide, and 3) assessment of changes in provider practices and clinical outcomes via EMR review.

Results: 34 hospitalist (74% physicians, remainder NPs/PAs) completed the needs assessment survey. 28 completed the online modules. The post module survey was completed anywhere from 1-2 years after the modules. In the needs assessment, 85% of respondents were either moderately or very motivated to learn about managing agitation. Hospitalists estimated seeing agitation several times per week or weekly 68% of the time pre-intervention and 78% of the time post-intervention. Confidence levels in the management of these patients improved. Pre-intervention, only 24%, 50%, and 18% of hospitalists were moderately or very confident in managing ABI, dementia and IDD, respectively. Post-intervention, 73%, 86%, and 66% of hospitalists were moderately or very confident in managing ABI, dementia and IDD, respectively.

Discussion: Phase one of this course demonstrated positive responses in terms hospitalists attitudes and confidence in management. Improvements in these metrics may not translate into improved patient outcomes, and results are restricted to one site. The launch at two additional Hopkins sites is underway. EMR review will allow us to assess practice and clinical outcomes pre- and post-dissemination of the curriculum. Metrics including rates/reason sitter use, rates/reason restraint use, and rates of falls secondary to agitation will provide insight into key aspects of practice and clinical outcome.

Conclusion: An online training module can be helpful in improving the confidence of managing agitation among hospitalists. Improving provider knowledge, attitudes, and skills has the potential to result in better patient outcomes.