Multidisciplinary Approach to Enhancing Safety and Care for Pediatric Behavioral Health Patients in Acute Medical Settings

Reducing Physical Restraint Use in the Medical Behavioral Unit

OBJECTIVES

Children with behavioral health conditions often experience agitation when admitted to children's hospitals. Physical restraint should be used only as a last resort for patient agitation because it endangers the physical and psychological safety of patients and employees. At the medical behavioral unit (MBU) in our children's hospital, we aimed to decrease the weekly rate of physical restraint events per 100 MBU patient-days, independent of patient race, ethnicity, or language, from a baseline mean of 14.0 to <10 within 12 months.

METHODS

Using quality improvement methodology, a multidisciplinary team designed, tested, and implemented interventions including a series of daily deescalation huddles led by a charge behavioral health clinician that facilitated individualized planning for MBU patients with the highest behavioral acuity. We tracked the weekly number of physical restraint events per 100 MBU patient-days as a primary outcome measure, weekly physical restraint event duration as a secondary outcome measure, and MBU employee injuries as a balancing measure.

RESULTS

Our cohort included 527 consecutive patients hospitalized in the MBU between January 2021 and January 2023. Our 2021 baseline mean of 14.0 weekly physical restraint events per 100 MBU patient-days decreased to 10.0 during our 2022 intervention period from January through July and 4.1 in August, which was sustained through December. Weekly physical restraint event duration also decreased from 112 to 67 minutes without a change in employee injuries.

CONCLUSIONS

Multidisciplinary huddles that facilitated daily deescalation planning safely reduced the frequency and duration of physical restraint events in the MBU.

Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department

BACKGROUND AND OBJECTIVES

Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints.

METHODS

A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints.

RESULTS

During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71.

CONCLUSIONS

Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.

De-escalation Techniques for the Agitated Pediatric Patient

ABSTRACT

The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.

Building a Nurse-Led Collaborative Care Delivery Model for Behavioral Health Patients Boarding on a Pediatric Medical Unit

With the current global mental health crisis, hospitals have experienced an exponential increase in behavioral health patients boarding on medical and surgical units. Nursing leaders are challenged with adapting existing infrastructure to deliver safe high-quality care to this patient population. This article describes 1 medical center's nurse-led effort to improve safety and quality care experiences for pediatric behavioral health patients boarding on a medical unit and for the staff providing care.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Role of Psychologists in Pediatric Subspecialties: Integrated Psychological Services Overarching Concepts Across Pediatric Subspecialties

This article addresses, in more general terms, the overarching concepts of the role of integrated psychologists and how their services are incorporated in the medical home with the use of provider consultation, administering assessments in identifying common mental health concerns, providing interventions for treatment adherence and providing short-term therapy within pediatric subspecialties.

Behavioural emergencies in a paediatric hospital environment

AIM

Aggression and high-risk behaviours triggered by children in paediatric hospitals are increasing globally. There is a paucity of research describing behavioural emergencies in paediatric acute care settings.

METHODS

We conducted a 1-year retrospective study of behavioural emergencies that triggered an emergency response team attendance in a quaternary paediatric hospital.

RESULTS

In 2018, 218 children triggered 1050 behavioural emergencies, which utilised 386 h of the emergency response team time. Thirty-three (15%) children triggered more than five activations each (range 6-272) and nearly half (16) were children with autism spectrum disorder or intellectual disability. More than 80% of children who triggered an emergency team response also had at least one psychiatric co-morbidity.

CONCLUSIONS

Behavioural emergencies, by definition, put staff, children or their families at risk. They occur frequently in hospital with some children repeating these behaviours despite allocation of resources and expertise. New approaches to prevention and amelioration are needed.

Acute psychiatric care for pediatric patients

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.