The Characteristics and Prevalence of Agitation in an Urban County Emergency Department

Study objective: We seek to determine the characteristics and prevalence of agitation among patients in an urban county emergency department (ED). Methods: This was a prospective observational study of ED patients at an urban Level I trauma center. All ED patients were screened during daily randomized 8-hour enrollment periods. Adult agitated patients, defined as having an altered mental status score greater than 1, were included. Trained research volunteers collected demographics and baseline data, including the presenting altered mental status score, use and type of restraints, and whether any initial sedative was given. The altered mental status score, vital signs, and any medications or treatments given were recorded every 5 minutes thereafter until the patient had an altered mental status score less than 1. Providers were asked to describe clinical events resulting in an intervention occurring during the patient course, including hypotension, vomiting, increased monitoring, use of supplemental oxygen or airway adjunct, or intubation. The provider also completed a checklist to determine the presence of delirium symptoms. Results: A total of 43,838 patients were screened (45.1% women; median age 33 years; range 0 to 102 years). The prevalence of agitation was 2.6% (1,146/43,838; median altered mental status score 2). Of these patients, 84% (969/1,146) required physical restraint and 72% (829/1,146) required sedation with an intramuscular injection. Sedative agents were olanzapine in 39% of patients (442/1,146), droperidol in 20% (224/1,146), haloperidol in 20% (226/1,146), a benzodiazepine in 6% (68/1,146), and ketamine in 5% (52/1,146). Delirium characteristics were observed in 0.6% of patients (260/43,838), representing 23% of agitated patients in the ED. Clinical events were observed in 13% of agitated patients (114/866) without delirium symptoms and 26% (68/260) with delirium symptoms. Characteristics associated with a clinical event included delirium symptoms (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.4), a cause related to a drug other than alcohol (OR 1.7; 95% CI 1.1 to 2.9), or a nondrug-induced cause of agitation (OR 3.5; 95% CI 2.3 to 5.6). Conclusion: The prevalence of agitation in the ED was 2.6%. Agitated patients frequently required restraint and sedation, with significant rates of clinical events requiring intervention.