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Analysis

Agitated Patients Face Wide-Ranging Risks in Emergency Departments

By Christopher Cheney  
   July 30, 2018

In the emergency room setting, agitated patients with delirium experience higher rates of hospital admissions and adverse events, researchers say.

Agitated patients represent a small but challenging portion of emergency department visits, researchers at an urban Level 1 trauma center found.

The researchers, who published their study this month in Annals of Emergency Medicine, screened 43,838 ER patients and found 1,146 (2.6%) were in an agitated state.

Agitated patients can require significant levels of care in the emergency department setting, the researchers wrote.

"We found that severe agitation occurs frequently in the ED, and often requires both chemical sedation and physical restraint to control the patient to allow a comprehensive medical evaluation and to protect medical providers and the patient from injury."

Acute states of agitation can be deadly, the researchers wrote. "Injuries and sudden deaths have been reported among agitated persons during attempts to restrain and care for them in both custodial arrests and medical stabilization."

None of the agitated patients in the Annals of Emergency Medicine research project died.

Data collected in the research project shows characteristics of agitated patients and their care:

  • 84.6% of agitated patients required physical restraint
     
  • 72.3% required sedation with an intramuscular injection
     
  • 1.8% required physical restraint and sedation
     
  • 16% had clinical events that required intervention such as mild hypoxia treated with supplemental oxygen
     
  • 7% experienced an adverse event—either intubation or hypotension
     
  • 23% had delirium symptoms

Delirium danger
 

Delirium is a serious condition for agitated patients, the researchers wrote.

"The rate of clinical and adverse events was much higher in patients with delirium symptoms, with a two-times-higher rate of intubation, two-times-higher rate of hypotension, and two-times-higher rate of hospital admissions."

Excited delirium syndrome, an acute form of delirium associated with extreme physical violence, is particularly problematic.

The American College of Emergency Physicians recognized excited delirium syndrome in 2009. For a diagnosis of excited delirium syndrome under the ACEP guidelines, a patient must exhibit at least six of 10 potential symptoms, including pain tolerance, sweating, agitation, lack of tiring, and unusual strength.

The Annals of Emergency Medicine researchers found that the histories and vital signs of delirium patients were similar, which indicated that different rates of complications for the patients could be caused by the nature of agitation associated with delirium. "This supports the theory that excited delirium syndrome may represent a condition that is higher risk than typical agitation," they wrote.

The stakes are high for excited delirium syndrome patients, the researchers wrote.

"Because the estimated mortality rate of patients with excited delirium syndrome may be as high as 16.5%, it is critical to identify treatments or interventions that may curb the metabolic derangements of patients with suspected excited delirium syndrome."

Recommendations
 

While more research is necessary to develop comprehensive best practices for the treatment of agitated patients, the researchers highlight several care guidelines.

  • In a minority of agitated patients, the condition is linked to a medical illness and performing a timely assessment is crucial, the researchers wrote. "Rapid assessment is imperative because previous research has demonstrated that up to 1% of similar patients ultimately require critical care resources while in the ED."
     
  • Oral sedatives are probably not appropriate for many agitated patients because they may not be rapid-acting enough or feasible for distraught patients who struggle with compliance.
     
  • If parenteral sedation is required, intramuscular injections can accomplish faster sedation than establishing an intravenous line for an agitated patient.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


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