P2.167: From IM to Empathy: A Structured, Low-Cost De-escalation Protocol to Reduce Restraint of Autistic Youth in the Emergency Department

Purpose/Objectives: To improve management of autistic youth in behavior crisis by reducing reliance on intramuscular (IM) medications and security interventions through implementation of a structured, low-cost, autism-informed de-escalation protocol in the emergency department.

Design/Methods: Autistic patients presenting in behavioral crises often face heightened risk of physical restraint and chemical sedation in emergency departments not designed or adapted for their needs. After a case involving overnight IM ziprasidone administration to a young teen with autism and no prior aggression, we launched a quality improvement initiative to disrupt this cycle.

A multi-disciplinary team including pediatrics, pharmacy, emergency medicine, psychiatry and nursing adapted and utilized a rapid-response, low-stimulation protocol. Core components included:
(1) Environmental controls: dimmed lighting, cleared rooms, reduced noise
(2) Communication shift: simple, concrete "if-then" phrases to reduce cognitive overload
(3) Sensory strategies: calming tools such as fidget objects and weighted blankets
(4) Tactical repositioning: relocating or repositioning visible security personnel during escalation
To sustain the protocol, at least one staff member per shift was briefly trained in basic de-escalation for autistic youth, including an ED pharmacist embedded in the escalation response.
Protocol activation was supported by just-in-time coaching and team huddles for feedback cycles.

Results: Following implementation of the de-escalation protocol, significant reductions in IM medications and security interventions have occurred. Staff confidence improved and patient escalations have been reduced. In one case, using the protocol resulted in reduction of IM medication use for an autistic patient by 75% and no subsequent physical restraint or sedation was needed. Front-line staff reported reduced anxiety, increased confidence and faster recovery times. The intervention has also contributed to a broader departmental shift in managing autistic patients with behavioral needs more safely and effectively.

Conclusion/Discussion: This simple intervention replaced fear-driven, high-cost responses with a simple, structured approach adapted to autistic patients. In a high-pressure ED environment where staff face safety concerns and limited resources, targeted de-escalation protocols grounded in autism-informed adaptive care can reduce reliance on pharmacological restraint and security interventions in the ED. Training front-line staff and optimizing the environment are low-cost, high-impact interventions to improve outcomes, reducing risk, and increasing staff satisfaction for youth with autism. With minimal resource investment, this model improved care quality, safety, and staff engagement and may be adapted across other institutions to drive safety, dignity and system resilience.