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Dean AL, Lambrese JV. Treating Children and Adolescents with Aggressive Behaviors in the Inpatient Setting. Pediatr Ann 2024; 53:e293-e298. [PMID: 39120453 DOI: 10.3928/19382359-20240605-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
The mental health crisis in children and adolescents presents a unique challenge for pediatric providers in the inpatient setting. Patients are presenting to the emergency department in acute psychiatric crises, but the increased need for behavioral health services is met with an already limited supply of behavioral health services and facilities. As such, these patients are hospitalized on acute care floors, which can serve to exacerbate symptoms of aggression regardless of cause and complicates treatment and harm prevention strategies. We present a comprehensive management approach to the acutely agitated pediatric patient with aggressive behaviors, including prevention of symptoms in patients with risk factors; nonpharmacological approaches to de-escalation, including the use of restraint; and common oral and parenteral psychopharmacological agents. Such strategies are considered from a medical, ethical, and legal standpoint with the goal of maintaining safety and minimizing harm to patients, families, and staff. [Pediatr Ann. 2024;53(8):e293-e298.].
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Mitchell M, Newall F, Bernie C, Brignell A, Williams K. Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings: A systematic review. Int J Nurs Stud 2024; 158:104842. [PMID: 38964221 DOI: 10.1016/j.ijnurstu.2024.104842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/31/2024] [Accepted: 06/10/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills. OBJECTIVE The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings. METHODS The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses. RESULTS Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes. CONCLUSIONS Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes. REGISTRATION PROSPERO Registration Number CRD42020151002. TWEETABLE ABSTRACT Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.
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Affiliation(s)
- Marijke Mitchell
- Department of Paediatrics, Monash University, Clayton, Melbourne, Australia; Royal Children's Hospital, Parkville, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, Australia; Monash Children's Hospital, Clayton, Melbourne, Australia.
| | - Fiona Newall
- Royal Children's Hospital, Parkville, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Melbourne, Australia
| | - Charmaine Bernie
- Department of Paediatrics, Monash University, Clayton, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Melbourne, Australia; Southern Cross University, Bilinga, Queensland, Australia
| | - Amanda Brignell
- Department of Paediatrics, Monash University, Clayton, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Melbourne, Australia; Monash Children's Hospital, Clayton, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Clayton, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Melbourne, Australia; Monash Children's Hospital, Clayton, Melbourne, Australia
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Hickox T, Brahmbhatt K, Smith JR, Fuchs C, Tanguturi Y. Consultation-Liaison Case Conference: Systemic Challenges in Management of Aggression in a Pediatric Patient With Seronegative Autoimmune Encephalitis. J Acad Consult Liaison Psychiatry 2024; 65:66-75. [PMID: 37625481 DOI: 10.1016/j.jaclp.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
We present the case of a 9-year-old girl who presented to a tertiary-care academic children's hospital with acute onset of severe obsessive-compulsive symptoms, perseveration, grimacing, and personality changes with resultant agitation. Extensive multidisciplinary workup led to a diagnosis of seronegative autoimmune encephalitis. The clinical course included multiple general pediatric and inpatient psychiatric unit admissions that were complicated by severe affective dysregulation with physical aggression towards staff and family. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of available literature. Key teaching points include assessment and management of seronegative autoimmune encephalitis and catatonia. We discuss the system-level challenges of management of aggression in health care settings and ways to improve care for patients presenting with behavioral manifestations (aggression) of physical illness.
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Affiliation(s)
- Tucker Hickox
- Augusta University Medical College of Georgia, Athens, GA.
| | - Khyati Brahmbhatt
- Department of Psychiatry and Behavioral Science, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Joshua R Smith
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Catherine Fuchs
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Yasas Tanguturi
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN; Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO
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Masserano B, Hall M, Wolf R, Diedrich A, Gupta A, Yu AG, Johnson K, Mittal V. Pharmacologic Restraint Use During Mental Health Admissions to Children's Hospitals. Pediatrics 2024; 153:e2023062784. [PMID: 38073316 DOI: 10.1542/peds.2023-062784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 01/02/2024] Open
Abstract
OBJECTIVES Primary mental health admissions are increasing across US children's hospitals. These patients may experience agitation requiring pharmacologic restraint. This study characterized pharmacologic restraint use in medical inpatient units by primary mental health diagnosis. METHODS This retrospective, cross-sectional study used the Pediatric Health Information System database. The study included children aged 5 to 17 years admitted with a primary mental health diagnosis between 2016 and 2021. Rates of pharmacologic restraint use per 1000 patient days were determined for 13 mental health diagnoses and trended over time with Poisson regression. RESULTS Of 91 898 hospitalizations across 43 hospitals, 3% of admissions and 1.3% of patient days involved pharmacologic restraint. Trends in the rate of pharmacologic restraint use remained stable (95% confidence interval [CI], 0.7-2.1), whereas the incidence increased by 141%. Diagnoses with the highest rates of pharmacologic restraint days per 1000 patient days included autism (79.4; 95% CI, 56.2-112.3), substance-related disorders (45.0; 95% CI, 35.9-56.4), and disruptive disorders (44.8; 95% CI, 25.1-79.8). The restraint rate significantly increased in disruptive disorders (rate ratio [RR], 1.4; 95% CI, 1.1-1.6), bipolar disorders (RR, 2.0; 95% CI, 1.4-3.0), eating disorders (RR, 2.4; 95% CI, 1.5-3.9), and somatic disorders (RR, 4.2; 95% CI, 1.9-9.1). The rate significantly decreased for autism (RR, 0.8; 95% CI, 0.6-1.0) and anxiety disorders (RR, 0.3; 95% CI, 0.2-0.6). CONCLUSIONS Pharmacologic restraint use among children hospitalized with a primary mental health diagnosis increased in incidence and varied by diagnosis. Characterizing restraint rates and trends by diagnosis may help identify at-risk patients and guide targeted interventions to improve pharmacologic restraint utilization.
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Affiliation(s)
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ryan Wolf
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Andrew Diedrich
- Child and Adolescent Psychiatry, Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
- Children's Medical Center, Dallas, Texas
| | - Ankita Gupta
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Andrew G Yu
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Katherine Johnson
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
| | - Vineeta Mittal
- Divisions of Hospital Medicine
- Children's Medical Center, Dallas, Texas
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Wolf RM, Hall M, Williams DJ, Antoon JW, Carroll AR, Gastineau KAB, Ngo ML, Herndon A, Hart S, Bell DS, Johnson DP. Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis. Pediatrics 2024; 153:e2023061353. [PMID: 38073320 PMCID: PMC10764008 DOI: 10.1542/peds.2023-061353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children's hospitals. METHODS We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity. RESULTS The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72-0.92), Asian (aOR, 0.82; 95% CI, 0.68-0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57-0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49-0.68), except for Hispanic males, and not found in females (aORs, 0.83-0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47-0.91). CONCLUSIONS Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.
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Affiliation(s)
- Ryan M Wolf
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Section on Hospital Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Derek J Williams
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - James W Antoon
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Carroll
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelsey A B Gastineau
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - My-Linh Ngo
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison Herndon
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Hart
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deanna S Bell
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Johnson
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
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.
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Affiliation(s)
| | - Carl R Baum
- Professor, Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Li J, Lee LK, Hudgins JD. Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments. Pediatrics 2023; 151:190312. [PMID: 36530158 DOI: 10.1542/peds.2022-056667] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described. METHODS This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint. RESULTS Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25). CONCLUSIONS For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco, California
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Emergency Medicine.,Pediatrics, Harvard Medical School, Boston, Massachusetts
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Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:80-88. [PMID: 37205041 PMCID: PMC10172545 DOI: 10.1176/appi.focus.23022005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Introduction Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Methods Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Results Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. Conclusion These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.
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Affiliation(s)
- Ruth Gerson
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
| | - Nasuh Malas
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
| | - Vera Feuer
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
| | - Gabrielle H Silver
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
| | - Raghuram Prasad
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
| | - Megan M Mroczkowski
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York (Gerson); University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan (Malas); Northwell Health, Department of Psychiatry, New Hyde Park, New York (Feuer); Weill Cornell Medical College, Department of Psychiatry, New York, New York (Silver); Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania (Prasad); Columbia University Medical Center, Department of Psychiatry, New York, New York (Mroczkowski)
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Ramsden SC, Pergjika A, Janssen AC, Mudahar S, Fawcett A, Walkup JT, Hoffmann JA. A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings. Acad Emerg Med 2022; 29:1466-1474. [PMID: 35490341 PMCID: PMC9622426 DOI: 10.1111/acem.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings. METHODS A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions. RESULTS A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical. CONCLUSIONS Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aron C. Janssen
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sukhraj Mudahar
- Department of Pharmacy, Children’s Hospital of Orange County, Orange, CA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL,Lurie Children’s Pediatric Research & Evidence Synthesis Center of Innovative Implementation Science & Engagement (PRECIISE): A JBI Affiliated Group, Chicago, IL
| | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Mitchell M, Newall F, Williams K. Behavioural emergencies in a paediatric hospital environment. J Paediatr Child Health 2022; 58:1033-1038. [PMID: 35147266 PMCID: PMC9305421 DOI: 10.1111/jpc.15896] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/15/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Marijke Mitchell
- Neurodevelopment & Disability, Nursing Research, Royal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia,Murdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsMonash University, Monash Children's HospitalMelbourneVictoriaAustralia
| | - Fiona Newall
- Neurodevelopment & Disability, Nursing Research, Royal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia,Murdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of NursingThe University of MelbourneMelbourneVictoriaAustralia
| | - Katrina Williams
- Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia,Department of PaediatricsMonash University, Monash Children's HospitalMelbourneVictoriaAustralia
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11
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Manuel MM, Feng S, Yen K, Patel F. The agitated pediatric patient located in the emergency department: The APPLIED observational study. J Am Coll Emerg Physicians Open 2022; 3:e12766. [PMID: 35769845 PMCID: PMC9208717 DOI: 10.1002/emp2.12766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/14/2022] [Accepted: 05/26/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3-year-period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non-Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2-2.7), but not restrained (aOR, 0.8; 95% CI, 0.3-1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5-3.3), autism (aOR, 2.9; 95% CI, 1.9-4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2-2.5), psychosis (aOR, 14.3; 95% CI, 2.5-271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2-3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0-3.5). Depression (aOR, 0.4; 95% CI, 0.3-0.5) and suicidality (aOR, 0.2; 95% CI, 0.1-0.3) were protective against agitation and restraint use. Conclusion Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.
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Affiliation(s)
- Matthias M. Manuel
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
| | - Sing‐Yi Feng
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
- North Texas Poison CenterParkland Health and Hospital SystemDallasTexasUSA
| | - Kenneth Yen
- Division of Emergency MedicineDepartment of PediatricsUniversity of Texas Southwestern Medical Center/Children's HealthDallasTexasUSA
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12
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Keller AR, Kanaley RL, Starr T, Strollo B, Scharf M, Massachi S, Angell L, Clough CD, Schriefer J. Mitigating Pediatric Inpatient Aggression: A Quality Improvement Initiative. Hosp Pediatr 2022; 12:499-506. [PMID: 35476133 DOI: 10.1542/hpeds.2021-006431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient aggression in the health care workplace has increased significantly, and the impact of workplace violence can be profound, including psychological trauma and lost productivity. We suspect these safety events are often unreported, leading to missed opportunities to design interventions to reduce harm. The primary aim of the interdisciplinary quality improvement team was to increase staff reporting of safety events utilizing our event reporting system related to the care of verbally and/or physically aggressive pediatric patients by 10% over a 12-month period. METHODS An interdisciplinary quality improvement team addressed existing gaps in the care of pediatric inpatients with escalating behavior. Interventions included a survey of staff knowledge, use of the care guideline for management, updates to the electronic medical record, patient aggression screening tool, an electronic order set, and an online education module. The primary outcome measure was the number of reported staff safety events related to the care of aggressive patients. Compliance with the use of the pediatric aggression risk screening tool was tracked as a process measure. RESULTS The reporting of safety events related to the care of aggressive patients increased from just <1.0 events per 1000 patient days to 3.0 with special cause variation observed on a statistical process control chart. The compliance with the use of the pediatric aggression risk screening tool improved during the time of the project, nearing 90%. CONCLUSIONS A variety of interventions aimed to address pediatric inpatient aggression can improve the reporting of events related to workplace violence and foster a culture of employee safety.
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Affiliation(s)
- Amy R Keller
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Rebecca L Kanaley
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Taylor Starr
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | - Bonnie Strollo
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York.,cStrong Memorial Hospital, Rochester, New York
| | - Michael Scharf
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
| | | | - Luke Angell
- eChildren's Medical Group, Poughkeepsie, New York
| | | | - Jan Schriefer
- aGolisano Children's Hospital, Rochester, New York.,bColumbia Memorial Health, Albany Medical Center, Hudson, New York
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13
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Foster AA, Porter JJ, Monuteaux MC, Hoffmann JA, Hudgins JD. Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments. J Pediatr 2021; 236:276-283.e2. [PMID: 33771581 DOI: 10.1016/j.jpeds.2021.03.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED). STUDY DESIGN We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use. RESULTS We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001). CONCLUSIONS Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | | | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Joel D Hudgins
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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14
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Addressing and Recognizing Pediatric Inpatient Aggression Utilizing an Interprofessional Quality Team Approach. Pediatr Qual Saf 2021. [PMCID: PMC8436880 DOI: 10.1097/pq9.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.
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15
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Vande Voort JL, Croarkin PE. Benchmarking and Optimizing Pharmacologic Restraint for Agitated Youth in the Emergency Medicine Department. J Pediatr 2021; 236:8-9. [PMID: 33901520 DOI: 10.1016/j.jpeds.2021.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 11/20/2022]
Affiliation(s)
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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16
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Predicting the time trend of first episodes of aggressive behaviors in pediatric psychiatric inpatient units. J Psychiatr Res 2021; 140:117-123. [PMID: 34111701 DOI: 10.1016/j.jpsychires.2021.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 03/30/2021] [Accepted: 05/21/2021] [Indexed: 02/03/2023]
Abstract
The goal of the current study is to assess whether the scores of Brief Rating of Aggression by Children and Adolescents (BRACHA) at the emergency room (ER) can predict the aggressive incidents at pediatric psychiatric inpatient units. The study aims to identify predictors for two outcome measurements: 1) hazard rates for the first aggressive incident and 2) numbers of days between admission and the first aggressive incident, using the Cox regression model and Poisson regression model, respectively. The clinical records of a total of 5,610 adolescents admitted into the pediatric psychiatric inpatient units of Cincinnati Children's Hospital Medical Center were extracted for the analysis. The aggressive incident was defined as a score >0 from any category of the Overt Aggression Scale (OAS) and the high-aggressive incident was defined as a score ≥ 2 from any category of the OAS. The results indicate that the BRACHA score was not associated with high-aggressive incidents (hazard ratio: 0.98, p = 0.7543). Similarly, the BRACHA scores was only associated with the number of days from admission to the first aggressive incident (Poisson regression coefficient: 0.24, p < 0.0001) but not the number of days from admission to the first high-aggressive incident (Poisson regression coefficient: 0.03, p = 0.3994). Furthermore, the second peak of first aggressive incidents during the hospitalization highlights the importance of interventions at the end of the inpatient treatment course. To summarize, BRACHA scores based on initial assessments at the ER could correlate with first aggressive incidents, but not the first high-aggressive incidents.
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17
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Mitchell M, Bernie C, Newall F, Williams K. Simulation-based education for teaching aggression management skills to health care providers in the acute health care setting: a systematic review protocol. Syst Rev 2020; 9:208. [PMID: 32887661 PMCID: PMC7487524 DOI: 10.1186/s13643-020-01466-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical aggression episodes, that is aggression and externalising behaviours that create risk, in acute care hospitals are increasing. Acute care staff are often not confident or trained in the management of aggression. Various aggression management training formats have been described in practice including face to face training, written learning resources, web- and media-based training resources, and simulation training. The aim of this systematic review is to assess whether simulation-based training is effective in increasing de-escalation knowledge, skills, and behaviour of staff working in the acute care setting. METHODS We designed and registered a study protocol for a systematic review of studies evaluating simulation-based training for the management of patients with aggression. We will include randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies including health care professionals and trainees in acute health care settings. Comprehensive searches will be conducted in the following databases (from January 1980 onwards): PubMed, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library. The reference lists of selected studies, trial registers, and leading journals will also be searched. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential discrepancies will be resolved through discussion. The primary outcomes will include patient outcomes (e.g. frequency of clinical aggression), quality of care (e.g. frequency of emergency situations, physical/chemical/mechanical restraint), and adverse effects (e.g. patient/family complaints, patient harms, staff harms). Secondary outcomes will include workplace resource use, health care provider-related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. The study methodological risk of bias will be appraised using appropriate tools. A narrative synthesis will be performed for included studies. If feasible, we will conduct random-effects meta-analysis of data. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. participant characteristics, interventions, and follow-up). DISCUSSION This systematic review will identify, evaluate, and integrate the evidence on simulation-based training programmes for acute care health professionals on managing clinical aggression. The results of this study will inform the implementation of effective training strategies. Implications for future research will be discussed. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42020151002.
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Affiliation(s)
- Marijke Mitchell
- Neurodevelopment & Disability, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia. .,Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia. .,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria, 3052, Australia.
| | - Charmaine Bernie
- Department of Allied Health, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Fiona Newall
- Nursing Research, Nursing Education, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Department of Nursing, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria, 3052, Australia
| | - Katrina Williams
- Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Education and Research, Monash Children's Hospital, Monash University, 246 Clayton Road, Clayton, Victoria, 3168, Australia
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18
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Mitchell M, Newall F, Sokol J, Heywood M, Williams K. Simulation-based education to promote confidence in managing clinical aggression at a paediatric hospital. Adv Simul (Lond) 2020; 5:21. [PMID: 32817808 PMCID: PMC7425032 DOI: 10.1186/s41077-020-00139-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/22/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND An increasing number of incidents involving aggressive behaviour in acute care hospitals are being witnessed worldwide. Acute care hospital staff are often not trained or confident in managing aggression. Competent management of clinical aggression is important to maintain staff and patient safety. Training programmes for acute care staff are infrequently described in the literature and rarely reported for paediatric staff. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management. AIM AND DESIGN The aim of this proof of concept study was to develop a simulation-based education session on aggression management for acute care paediatric staff based on best practice principles, to evaluate the acceptability of this training programme and to gain an understanding of the impact of the training on participants' perceived confidence in managing clinical aggression. Two separate simulation exercises were delivered as a 2-h component of a hospital management of clinical aggression (MOCA) training day. Participants completed a written survey immediately prior to, at completion of the simulation-based group training, and at 3-6 months following the simulation training. FINDINGS Nine training days were conducted in 2017 for nursing, medical, allied health, education and security staff with a total of 146 participants (83% were acute care nurses). Two thirds (68%) of participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following the simulation training, 80% of all participants reported feeling more confident in managing clinical aggression, 47% reported a 1-point increase in confidence, whilst 33% of participants reported a 2- or 3-point increase. At 3-6 months post-training, 66% of respondents (N = 44) reported continued confidence in managing aggression with 100% of participants stating they would recommend simulation training to colleagues. CONCLUSIONS Simulation training is an acceptable method of training and shows promise to improve staff-perceived confidence for managing behavioural emergencies in acute paediatric health care settings. In addition, there were potential enduring positive impacts at 3 months after the study. Whilst resource and time intensive, further research assessing the benefits of utilising simulation training in this setting is warranted in order to minimise staff burn-out and improve outcomes for these very vulnerable patients.
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Affiliation(s)
- Marijke Mitchell
- Neurodevelopment & Disability, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Murdoch Children’s Research Institute, 50 Flemington Road, Parkville, Victoria, 3052 Australia
| | - Fiona Newall
- Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Murdoch Children’s Research Institute, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Department of Nursing, The University of Melbourne, 50 Flemington Road, Parkville, Victoria 3052 Australia
- Nursing Research, Nursing Education, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria 3052 Australia
| | - Jennifer Sokol
- Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- The RCH Simulation Program, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria 3052 Australia
| | - Melissa Heywood
- The RCH Simulation Program, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria 3052 Australia
| | - Katrina Williams
- Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Murdoch Children’s Research Institute, 50 Flemington Road, Parkville, Victoria, 3052 Australia
- Department of Paediatrics, Education and Research, Monash Children’s Hospital, Monash University, 246 Clayton Road, Clayton, Victoria, 3168 Australia
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19
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Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med 2019; 20:409-418. [PMID: 30881565 PMCID: PMC6404720 DOI: 10.5811/westjem.2019.1.41344] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/12/2019] [Accepted: 01/20/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Methods Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Results Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. Conclusion These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.
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Affiliation(s)
- Ruth Gerson
- Bellevue Hospital/New York University, Department of Psychiatry, New York, New York
| | - Nasuh Malas
- University of Michigan, Departments of Psychiatry and Pediatrics, Ann Arbor, Michigan
| | - Vera Feuer
- Northwell Health, Department of Psychiatry, New Hyde Park, New York
| | - Gabrielle H Silver
- Weill Cornell Medical College, Department of Psychiatry, New York, New York
| | - Raghuram Prasad
- Children's Hospital of Philadelphia, Department of Psychiatry, Philadelphia, Pennsylvania
| | - Megan M Mroczkowski
- Columbia University Medical Center, Department of Psychiatry, New York, New York
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20
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Gerson R, Malas N, Mroczkowski MM. Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2018; 27:367-386. [PMID: 29933788 DOI: 10.1016/j.chc.2018.02.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.
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Affiliation(s)
- Ruth Gerson
- Department of Child and Adolescent Psychiatry, New York University Langone, 462 1st Avenue, New York, NY 10016, USA.
| | - Nasuh Malas
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, C.S. Mott Children's Hospital, University of Michigan Hospital System, 1500 East Medical Center Drive, L5023, SPC 5277, Ann Arbor, MI 48109-5277, USA; Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Hospital System, 1500 East Medical Center Drive, L5023, SPC 5277, Ann Arbor, MI 48109-5277, USA
| | - Megan M Mroczkowski
- Department of Psychiatry, Columbia University Medical Center, 3959 Broadway CHONY 6N, New York, NY 10032, USA
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