Oral Medications for Treating Agitation in a Safety Net Emergency Department

Best-practice guidelines recommend oral medications for treating agitation in the emergency department (ED). However, there is limited study of their use in the ED, especially in the setting of drug and alcohol intoxication.

To evaluate the implementation of oral medications to treat agitation in an ED in which intramuscular medications were standard and to increase the use of oral medications to treat agitation.

This quality improvement study analyzed 2 populations. First, all ED patients in an urban level 1 adult and pediatric trauma center from January 1, 2018, to May 31, 2024, were studied to compare the preintervention and postintervention periods. Second, during the 12-month implementation period from September 16, 2020, to August 31, 2021, patients were prospectively observed in an area of the ED dedicated to caring for patients with drug and alcohol intoxication.

Oral medications to treat agitation, including olanzapine and lorazepam, were encouraged via education and real-time feedback for ED staff.

The primary outcome was the proportion of patients receiving their first sedating medication via the oral route. Secondary outcomes included data on time to adequate sedation and adverse drug events.

Of 460 600 ED encounters (median patient age, 38 years [IQR, 27-55 years]; 57.8% men; 184 050 [40.0%] before the intervention, 276 550 [60.0%] after), the proportion of patients receiving any sedating medication was similar between time periods (11.8% before intervention vs 11.5% after). The proportion of patients receiving their first sedating medication via the oral route increased after the intervention (7.2% vs 31.4%; difference, 24.2 percentage points [pp] [95% CI, 23.6-24.8 pp]). Among 1178 patients receiving sedating medications during implementation (860 [73.0%] with alcohol intoxication; median breath or blood concentration, 0.22% [IQR, 0.16%-0.28%]), 630 (53.5%) were offered oral medication, of whom 446 (70.8%) accepted it. Time to adequate sedation was 15 minutes (IQR, 7-33 minutes) for oral and 15 minutes (IQR, 9-26 minutes) for intramuscular medications (median difference, 1 minute [95% CI, -0.6 to 2.6 minutes]). There were no significant differences between routes in rates of additional rescue medications (oral, 31.8%; intramuscular, 28.4%; difference, 3.4 pp [95% CI, -2.0 to 8.8 pp]) or adverse drug reactions (oral, 2.7%; intramuscular, 1.1%; difference, 1.6 pp [95% CI, -0.1 to 3.3 pp]).

In this quality improvement study, emergency physicians successfully adopted oral medications for treating agitation, primarily from intoxication. No difference was found in time to adequate sedation when oral or intramuscular medications were used as primary therapy. These data support best-practice guidelines that suggest oral medications should be first-line treatment for agitation in the ED.