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.

BackgroundThe shortage of mental health services across the United States has turned pediatric emergency departments (PEDs) into safety‐nets for the increasing population of children with mental and behavioral health (MBH) needs. This study provides a descriptive characterization of MBH‐related PED visits, the trends in visit, ED length of stay (EDLOS), and admission rate.MethodsWe reviewed electronic health records of children ≤18 years with MBH needs, who visited the PED of a large tertiary hospital from January 2017 to December 2019. We performed descriptive statistics, chi‐square (χ2), and logistic regression analyses to evaluate trend in visit, EDLOS, admission rate, and predictors of prolonged EDLOS and inpatient admission.ResultsOf 10,167 patients, 58.4% were females, median age was 13.8 years, and 86.1% were adolescents. On average, visits increased by 19.7% annually, with a 43.3% increase over 3 years. Common ED diagnoses include, suicidality (56.2%), depression (33.5%), overdose/poisoning, and substance use (18.8%), and agitation/aggression (10.7%). Median EDLOS was 5.3 hr, average admission rate was 26.3%, with 20.7% boarding in the ED for >10 hr. Independent predictors of admission include depression (pOR: 1.5, CI: 1.3–1.7), bipolar disorder (pOR: 3.5, CI: 2.4–5.1), overdose/substance use disorder (pOR: 4.7, CI: 4.0–5.6), psychosis (pOR: 3.3, CI: 1.5–7.3), agitation/aggression (pOR: 1.8, CI: 1.5–2.1), and ADHD (pOR: 2.5, CI: 2.0–3.0). Principal independent driver of prolonged EDLOS was patient admission/transfer status (pOR: 5.3, CI: 4.6–6.1).ConclusionsGiven the study results, MBH‐related PED visits, ED length‐of‐stay, and admission rates continue to rise even in recent years. PEDs lack the resources and capability to provide high‐quality care for the increasing population of children with MBH needs. Novel collaborative approaches and strategies are urgently needed to find lasting solutions.

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ObjectivesThis study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.MethodsWe retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study period, specifically comparing patient demographics, diagnosis categories, and ED disposition between the pre-COVID (2019) and COVID (2020) periods using pairwise Pearson χ2 analyses with reported odds ratios (ORs) in SAS statistical software version 9.4 (SAS Institute Inc, Cary, NC).ResultsOf 8093 MBH-related visits, 58.5% were females, 85.4% were adolescents, and 62.7% self-identified as non-Hispanic. The proportion of MBH-related ED visits increased from 3.8% to 7.5% over the study period (P < 0.0001). Although total MBH visits decreased by 17.3% from 2019 to 2020, there was a proportionate increase in MBH-to-total-ED visits, representing a 42.8% increase through 2019. Compared with 2019, there was a proportionate increase in MBH-related ED visits by females (10.6%, P < 0.0001), older adolescents (18.2%, P < 0.0001), and non-Hispanic patients (6.1%, P = 0.017) in 2020. The MBH visits in 2020 were more likely related to suicidality/self-harm (OR, 1.2; confidence interval [CI], 1.1–1.4) or substance use (OR, 1.4; CI, 1.1–1.9). Compared with 2019, there were significantly higher odds of admission (OR, 1.6; CI, 1.3–2.1) or transfer for inpatient psychiatric care (OR, 1.8; CI, 1.6–2.1) in 2020.ConclusionsOur data suggest that the early COVID-19 pandemic had a significant impact on MBH-related ED visits. Compared with 2019, we observed a significant increase in the proportion of MBH-to-total-ED visits primarily affecting older adolescent, non-Hispanic girls with suicidality/self-harm and substance-related disorders in 2020, despite an overall decrease in the number of MBH visits during this period. There was also an increase in the proportion of visits resulting in admission or transfer for inpatient psychiatric care in 2020.

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