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Wnorowska JH, Naik V, Ramgopal S, Watkins K, Hoffmann JA. Characteristics of pediatric behavioral health emergencies in the prehospital setting. Acad Emerg Med 2024; 31:129-139. [PMID: 37947152 PMCID: PMC10922610 DOI: 10.1111/acem.14833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/19/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.
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Affiliation(s)
- Julia H Wnorowska
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vishal Naik
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Sriram Ramgopal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Kenshata Watkins
- Divison of Pediatric Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jennifer A Hoffmann
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Tang AS, Shieh MS, Pekow PS, Prentiss KA, Lindenauer PK, Westafer LM. Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments. Acad Emerg Med 2023; 30:1029-1038. [PMID: 37259900 PMCID: PMC11075781 DOI: 10.1111/acem.14754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use. METHODS This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications. RESULTS Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47). CONCLUSIONS We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment.
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Affiliation(s)
- Andrew S Tang
- Pediatric Emergency Medicine, Rady Children's Hospital, San Diego, California, USA
- Pediatric Emergency Medicine, University of California-San Diego, San Diego, California, USA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Penelope S Pekow
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts, USA
| | - Kimball A Prentiss
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Peter K Lindenauer
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Division of Hospital Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lauren M Westafer
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
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Hoffmann JA, Pergjika A, Liu L, Janssen AC, Walkup JT, Johnson JK, Alpern ER, Corboy JB. Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department. Pediatrics 2023; 152:e2022059586. [PMID: 37317809 PMCID: PMC10312235 DOI: 10.1542/peds.2022-059586] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Sciences
| | - Lynn Liu
- Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Sciences
| | - Julie K. Johnson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Zorovich EV, Kothari K, Adelgais K, Alter R, Mojica L, Salinas A, Auerbach M, Adams C, Fishe J. Prehospital Management of Pediatric Behavioral Health Emergencies: A Scoping Review. Cureus 2023; 15:e38840. [PMID: 37303422 PMCID: PMC10254945 DOI: 10.7759/cureus.38840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Pediatric behavioral health emergencies (BHE) are increasing in prevalence, yet there are no evidence-based guidelines or protocols for prehospital management. The primary objective of this scoping review is to identify prehospital-specific pediatric BHE research and publicly available emergency medical services (EMS) protocols for pediatric BHE. Secondary objectives include identifying the next priorities for research and EMS protocol considerations for children with neurodevelopmental conditions. This is a scoping review comprised of a research literature search for publications from 2012-2022 and an internet search for publicly available EMS protocols from the United States. Included publications contain data on the epidemiology of pediatric BHE or describe prehospital management of pediatric BHE. EMS protocols were included if they had advisements specific to pediatric BHE. A total of 50 research publications and EMS protocols from 43 states were screened. Seven publications and four protocols were included in this study. Research studies indicated an increase in pediatric BHE over the last decade, but few papers discuss current prehospital management (n=4). Two EMS protocols were specific to pediatric BHE or pediatric agitation, and the other two EMS protocols focused on adult populations with integrated pediatric recommendations. All four EMS protocols encouraged nonpharmaceutical interventions prior to the use of pharmacologic restraints. Although there is a substantial rise in pediatric BHE, there is sparse research data and clinical EMS protocols to support best practices for prehospital pediatric BHE management. This scoping review identifies important future research aims to inform best practices for the prehospital management of pediatric BHE.
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Affiliation(s)
- Elizabeth V Zorovich
- Pediatric Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Kathryn Kothari
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Kathleen Adelgais
- Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Rachael Alter
- Emergency Medicine Services, Emergency Medicine Services for Children Innovation and Improvement Center, Austin, USA
| | - Lia Mojica
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Aaron Salinas
- Emergency Medicine Services, University of Texas Rio Grande Valley, Edinburg, USA
| | - Marc Auerbach
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, USA
| | - Carrie Adams
- Borland Library, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Jennifer Fishe
- Pediatric Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Rotella JA. No one brain is the same: A neurodivergent clinician's approach to caring for the neurodivergent patient in the emergency department. Emerg Med Australas 2022; 34:613-615. [PMID: 35764294 DOI: 10.1111/1742-6723.14039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Joe-Anthony Rotella
- SPECTRE (Substance use, Psychiatry, Envenomation, Clinical Toxicology and Recreational substances) Unit, Northern Health, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Northern Health, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
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