There are scores of textbooks, videos and other educational resources to teach long-term-care staff members how to prevent injury to patients and their care teams when a patient becomes confused, frightened or irrational in long-term-care settings.

But a team of Johns Hopkins researchers, led by psychiatrist and consultation liaison Idris Leppla, found few resources geared toward teaching hospital care teams how to manage agitated patients in a general medical setting. Their extensive literature review was published in the Journal of the Academy of Consultation-Liaison Psychiatry.  

“More than 80% of the literature we looked at is oriented to treat patients with major cognitive disorders in long-term facilities,” says Leppla, assistant professor of psychiatry and behavioral sciences. “That’s a whole different situation than what we see in the hospital.”

When a patient admitted to the hospital for a nonpsychiatric issue has a psychiatric problem, physicians and staff members know to contact the on-call consultation liaison, a psychiatrist trained to manage patient agitation and assist the attending physician.

Leppla was recently called to assist with a middle-aged man admitted to Johns Hopkins Bayview Medical Center with severe liver disease. The man became agitated, threatening and spitting at the physicians, nurses and technicians charged with caring for him. Insisting he possessed superpowers, the patient repeatedly stood on his hospital bed and leapt off, as if he were flying.

His physician recognized the problem: A build-up of ammonia in the patient’s blood had caused hepatic encephalopathy, a condition that can lead to confusion, coma and even death.

After assessing the situation, Leppla and the care team restrained the patient and administered lactulose, a synthetic sugar used to treat hepatic encephalopathy. When the patient cleared the ammonia from his system, his agitation stopped and he no longer required restraints.

Leppla says stress, fever, and alcohol or drug withdrawal are among the many reasons that hospitalized patients may become agitated and potentially dangerous to themselves and members of their care team.

According to the American Hospital Association, health care workers suffer more workplace violence and injury than any other profession. Forty-four percent of nurses report an increase in physical violence since the COVID-19 pandemic, while 68% report an increase in verbal abuse. Each year in the United States, patients assault 20% of hospital workers, with 9 out of 10 incidents occurring on inpatient units.

Nurses, nursing assistants and care technicians are at greatest risk for workplace injury when faced with an agitated patient.

“While agitated behaviors … have different etiologies,” Leppla and her colleagues write, “there are general principles of agitation management that apply across the board, including verbal de-escalation, knowledge of environmental triggers, and awareness of when emergency medications may be appropriate.”

Leppla believes that knowing how to recognize and respond to such situations should be required training.

“In medical school, they teach students how to do things like insert chest tubes, but not how to manage agitated patients,” she points out.