A National Analysis on Statewide Prehospital Adult Behavioral Sedation Protocols with a Focus on Trends in Ketamine...

Prehospital clinicians are trained to treat medical emergencies and operate under treatment protocols that may be statewide, regional, or agency-specific. Prehospital treatment of behavioral health emergencies (BHE), especially with ketamine, has gained public attention over the past decade.

This study describes the current characteristics of prehospital statewide adult BHE protocols used across the United States (US) with a focus on trends in ketamine administration.

We conducted a cross-sectional review of mandatory and model statewide emergency medical service protocols and identified adult BHE protocols for inclusion. State protocols with a median publication year of 2023 were examined to evaluate protocol characteristics and the use of benzodiazepines, antipsychotics, and ketamine. A subset of current protocols was compared to archived versions to assess changes in ketamine use.

Thirty-two states representing 47% of the US population had statewide BHE protocols. Most protocols included verbal de-escalation, physical restraint, and postrestraint monitoring requirements. Less commonly found were objective scoring systems for agitation, process assurance indicators, and alternative destinations. The most frequently used medications included midazolam (n = 29; 91%), ketamine (n = 29; 91%), and haloperidol (n = 21; 66%). A temporal assessment of ketamine in BHE protocols revealed increasing adoption accompanied by expanded safety precautions.

This cross-sectional study of 32 US prehospital BHE protocols found relative inter-regional agreement except for a few notable differences, such as medication choice between protocols. During the study period, ketamine use in BHE protocols became more common with a shift toward enhanced safety precautions and uniform dosage guidelines.