The Agitated Psychotic Patient: Guidelines to Ensure Staff and Patient Safety

Patient-perpetrated violence is a serious problem that affects large numbers of nursing and healthcare staff. Incidents of assaultive behavior can lead to patient and staff injury, loss of productivity, and increased stress and burnout among healthcare professionals. The use of restraints for aggressive or assaultive behavior is governed by guidelines of the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services. Guidelines for dealing with the acutely agitated patient have recently been published by an expert consensus panel. All three sources agree that the use of nonphysical forms of behavior management (e.g., verbal intervention or show of force) is the appropriate first-line strategy. If medication is required, the current recommendation is the use of oral forms rather than intramuscular (IM) preparations, such as haloperidol and lorazepam, which have been the standard of care for many years. The primary disadvantages of injectables are the potential for injury and trauma to the patient, which is of special relevance for patients with paranoia, confusion, or previous assaults. Recent results suggest that oral formulations of atypical antipsychotics (e.g., risperidone) in combination with oral benzodiazepines (e.g., lorazepam) are as effective as similar IM treatments (e.g., haloperidol) in reducing psychotic agitation. Although additional large-scale studies are needed, early findings suggest that these oral formulations offer a less traumatic form of treatment than conventional IM drugs. For patients who will not accept oral medication, IM formulations of newer drugs are under investigation. These drugs (e.g., olanzapine, ziprasidone) may offer lower risk of side effects compared with older medications like haloperidol.