Incidence and predictors of delirium-associated violence towards healthcare workers in a Swiss ICU: results from the CAVE study
Abstract
Background: To assess the frequency of delirium coinciding with aggressive and/or violent patient behavior in intensive care unit (ICU) patients as documented by nurses and to identify clinical associations or risk factors.
Methods: This was a retrospective observational cohort study conducted at University Hospital Basel in Switzerland including data from 2023-2024. Data collected included demographics, treatment characteristics, clinical scores (including the Richmond Agitation-Sedation Score [RASS] and the Intensive Care Delirium Screening Checklist [ICDSC]) and interventions. The primary objective was to assess the prevalence of delirium in patients with aggressive/violent behavior within ±72 hours of incidents. Secondary objectives included identifying independent associations with violence via uni- and multivariable logistic regression.
Results: Of 10,817 ICU patients, 300 (2.8%) were reportedly aggressive or violent. Delirium occurred in 89.3% of patients within 72 hours of the event and 76.7% were delirious at event. Violence was mostly physical (80.4%), with 22.2% preceded by aggression within a median of 21.6 hours. Multivariable analyses identified an increasing RASS (OR = 1.46 per increasing unit ; p = 0.001) and ICDSC (OR = 1.14 per increasing unit ; p = 0.039) before the violent incident as independent associations. Management shifted from verbal de-escalation for aggression to more invasive measures for violence; sedation rose from 45.3% to 69.8% (p < 0.001), restraint use from 20.0% to 43.1% (p < 0.001) and sedation-related complications reached 64.9%. Unchanged one-on-one nursing rates indicate a reliance on restrictive measures over staffing increases.
Conclusions: While ICU-related aggression and violence is rarely reported, the independent association of increasing RASS/ICDSC scores before violence and a prodromal phase of aggression in many cases provide a warning pattern. Identifying these early signs could allow for proactive de-escalating intervention, potentially reducing the need for physical restraints and heavy sedation.
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BibTeX
@article{berger2026incidence,
title = {{Incidence and predictors of delirium-associated violence towards healthcare workers in a Swiss ICU: results from the CAVE study}},
author = {Sebastian Berger and Anja I. Frei and Pascale Grzonka and Simon A. Amacher and Caroline E. Gebhard and Sabina Hunziker and Raoul Sutter},
journal = {BMC Medicine},
year = {2026},
month = oct,
doi = {10.1186/s12916-026-05291-z},
url = {https://link.springer.com/10.1186/s12916-026-05291-z},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Incidence and predictors of delirium-associated violence towards healthcare workers in a Swiss ICU: results from the CAVE study
AU - Sebastian Berger
AU - Anja I. Frei
AU - Pascale Grzonka
AU - Simon A. Amacher
AU - Caroline E. Gebhard
AU - Sabina Hunziker
AU - Raoul Sutter
PY - 2026
DA - 2026/10/07
JO - BMC Medicine
DO - 10.1186/s12916-026-05291-z
UR - https://link.springer.com/10.1186/s12916-026-05291-z
AB - Background: To assess the frequency of delirium coinciding with aggressive and/or violent patient behavior in intensive care unit (ICU) patients as documented by nurses and to identify clinical associations or risk factors. Methods: This was a retrospective observational cohort study conducted at University Hospital Basel in Switzerland including data from 2023-2024. Data collected included demographics, treatment characteristics, clinical scores (including the Richmond Agitation-Sedation Score [RASS] and the Intensive Care Delirium Screening Checklist [ICDSC]) and interventions. The primary objective was to assess the prevalence of delirium in patients with aggressive/violent behavior within ±72 hours of incidents. Secondary objectives included identifying independent associations with violence via uni- and multivariable logistic regression. Results: Of 10,817 ICU patients, 300 (2.8%) were reportedly aggressive or violent. Delirium occurred in 89.3% of patients within 72 hours of the event and 76.7% were delirious at event. Violence was mostly physical (80.4%), with 22.2% preceded by aggression within a median of 21.6 hours. Multivariable analyses identified an increasing RASS (OR = 1.46 per increasing unit ; p = 0.001) and ICDSC (OR = 1.14 per increasing unit ; p = 0.039) before the violent incident as independent associations. Management shifted from verbal de-escalation for aggression to more invasive measures for violence; sedation rose from 45.3% to 69.8% (p < 0.001), restraint use from 20.0% to 43.1% (p < 0.001) and sedation-related complications reached 64.9%. Unchanged one-on-one nursing rates indicate a reliance on restrictive measures over staffing increases. Conclusions: While ICU-related aggression and violence is rarely reported, the independent association of increasing RASS/ICDSC scores before violence and a prodromal phase of aggression in many cases provide a warning pattern. Identifying these early signs could allow for proactive de-escalating intervention, potentially reducing the need for physical restraints and heavy sedation.
SN - 1741-7015
ER -