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

Document Type

Article

Publication Title

Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors

Abstract

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

METHODS: We performed a cross-sectional review of STPs in the United States in 2018 and 2025 as a measure of regional EMS clinical standards related to agitation management. We examined protocols related to agitation and extracted data regarding 11 recommendations from the NAEMSP Position Statement on clinical care and restraint of agitated or combative patients. These recommendations include 1) specific protocols for dealing with these patients, 2) use of 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) prohibition of restraint techniques, 9) monitoring after restraint or pharmacologic management, 10) prioritization of EMS clinician safety, and 11) description of when law enforcement should be involved. We calculated the proportion of states with each protocol recommendations. An EMS Physician adjudicated any discrepancies or difficulties in data collection.

RESULTS: There were 29 STPs in 2018 and 31 STPs in 2025. Between 2018 and 2025, there was an increase in the 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%), prohibition of prone positioning (72% vs 80%), monitoring after restraint or pharmacologic management (55% vs 71%), prioritization of EMS clinician safety (93% vs 97%), and description of when law enforcement should be involved (76% vs 81%). The proportion of STPs recommending specific protocols for dealing with an agitated, violent, or combative individual remained the same between 2018 and 2025 (97% vs 97%). Three states included all 11 assessed recommendations from the revised NAEMSP Position Statement.

CONCLUSIONS: Changes from 2018 to 2025 in STPs reflect limited implementation of recently updated national guidelines in the context of public attention to these clinical scenarios, 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, there continues to be an opportunity for an increased proportion of STPs to align with national recommendations on management of agitation.

First Page

1

Last Page

12

DOI

10.1080/10903127.2025.2608105

Publication Date

1-5-2026

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