TOPLINE:

In a quality improvement study, physicians successfully increased the use of oral medication for treating agitation in the emergency department (ED), with time to adequate sedation and safety not significantly different from those achieved with intramuscular injections.

METHODOLOGY:

• This quality improvement study analyzed 460,600 ED encounters (median patient age, 38 years; 57.8% men; 44.8% Black individuals; 30.0% White individuals; 6.5% American Indian or Alaska Native individuals; 2.1% Asian individuals; 14.3% Hispanic individuals; 0.2% Native Hawaiian or Other Pacific Islander individuals; and 2.1% of individuals with unknown or undisclosed race and ethnicity) of an urban, county, safety net, level 1 adult and pediatric designated trauma center from January 2018 to May 2024.
• Researchers evaluated two populations. For the first, ED encounter data were extracted from electronic medical records for periods before and after the intervention (2018-2024). For the second, a prospective cohort of patients (14.4% of total) was monitored during active implementation (2020-2021), with trained staff observing patients 24 hours a day in a locked unit.
• The primary outcome was the rate of receiving oral sedating medication as first-line treatment, and secondary outcomes included the time to adequate sedation and rates of adverse events.

TAKEAWAY:

• The proportion of patients receiving oral sedating medication as first-line treatment increased from 7.2% before the intervention to 31.4% after the intervention (percentage point difference [PPD], 24.2; 95% CI, 23.6-24.8).
• Among 1178 patients receiving sedating medications during implementation, 630 (53.5%) were offered oral medication, and 446 (70.8%) accepted it.
• The time to adequate sedation did not significantly differ between the oral and intramuscular routes, with a median difference of 1 minute (95% CI, -0.6 to 2.6).
• No significant differences were found between the two routes in the rates of additional rescue medications (PPD, 3.4; 95% CI, -2.0 to 8.8) or adverse reactions (PPD, 1.6; 95% CI, -0.1 to 3.3).

IN PRACTICE:

"We did not detect a difference in time to adequate sedation when PO [per os] or IM [intramuscular] medications were used as primary therapy," the authors wrote. "These data support best practice guidelines that suggest oral medications should be first-line treatment for agitation in the ED," they concluded.

SOURCE:

The study was led by Jon Cole, MD, Department of Emergency Medicine, Hennepin Healthcare, Minneapolis. It was published online on December 30, 2025, in JAMA Network Open.

LIMITATIONS:

The findings from this urban safety-net ED might not be applicable to other settings. The study primarily focused on agitation due to drug and alcohol intoxication, limiting applicability to agitation from other causes. Patient and caregiver satisfaction with oral medication was not assessed, although fewer violent incidents against healthcare workers were observed with oral medications.

DISCLOSURES:

This study was funded by the Department of Emergency Medicine at Hennepin Healthcare and did not receive any external funding. The authors reported having no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.