Evolution Over Time of EMS Statewide Treatment Protocols on Prehospital Agitation in the United States

Emergency medical services (EMS) clinicians' management of agitated patients have recently been highlighted by several high-profile events and the update of a National Association of EMS Physicians (NAEMSP) Position Statement. Our objective was to assess changes in EMS statewide treatment protocols (STP) for agitation over a 7-year period considering these events.

We performed a cross-sectional review of STPs in the U.S. in 2018 and 2025. We examined protocols related to agitation and extracted data regarding 11 recommendations from the NAEMSP Position Statement, including 1) specific protocols, 2) a standardized agitation score, 3) assessment for medical causes of agitation, 4) do not restrain a patient solely by law enforcement request, 5) verbal de-escalation, 6) physical restraint protocol, 7) pharmacologic management protocol, 8) prohibited restraint techniques, 9) patient monitoring, 10) prioritization of EMS clinician safety, and 11) when law enforcement should be involved. We calculated the proportion of states with each protocol recommendations. An EMS Physician adjudicated any discrepancies in data collection.

There were 29 STPs in 2018 and 31 STPs in 2025. Between 2018 and 2025, a larger proportion of STPs with 10 of the 11 recommendations: standardized agitation score (10% vs 29%), assessment for medical causes of agitation (90% vs 97%), do not restrain a patient solely by law enforcement request (0% vs 16%), verbal de-escalation (66% vs 100%), physical restraint protocol (97% vs 100%), pharmacologic management protocol (97% vs 100%), prohibited restraint techniques (72% vs 80%), patient monitoring (55% vs 71%), prioritization of clinician safety (93% vs 97%), and when law enforcement should be involved (76% vs 81%). The proportion of STPs with specific protocols for agitated patients remained similar between 2018 and 2025 (97% vs 97%). Three states included all 11 assessed recommendations from the revised NAEMSP Position Statement.

Changes from 2018 to 2025 in STPs reflect limited implementation of recently updated national guidelines, including increased recommendations for verbal de-escalation, limited recommendations for objective agitation assessment and patient monitoring, and increased recommendations for use of ketamine. Based on our findings, STPs have an opportunity to align with national recommendations on agitation management.