Patient Risk Factors for Violent Restraint Use in a Children’s Hospital Medical Unit

Noah, Akaninyene; Andrade, Gabriela; DeBrocco, Dawn; Dunn, Michelle; Herz, Katherine; Worsley, Diana; Camacho, Pete; Doupnik, Stephanie K.

doi:10.1542/hpeds.2020-000273

Cited by 10 publications

(5 citation statements)

References 21 publications

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“…We found that males were more likely to be restrained, which was similar to that found in prior studies on restraint use in the prehospital setting among adults, 2 in inpatient pediatric units, 30 and in EDs among children 23,24 . In contrast, prior studies in inpatient psychiatric and medical units did not find differences in restraint use by sex, 31–33 which could be due to differences in the patient population, physical environment, or staff training. In the ED, it has been found that adolescents are more likely to be physically restrained than younger children, 23,24 while a meta‐analysis of restraint use among inpatient mental health units found that younger children were more likely to be restrained 30 .…”

Section: Discussionsupporting

confidence: 84%

Characteristics of pediatric behavioral health emergencies in the prehospital setting

Wnorowska,

Naik,

Ramgopal

et al. 2023

Academic Emergency Medicine

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ObjectiveApproximately 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.MethodsWe conducted a retrospective cross‐sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019‐2020 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.ResultsOf 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% were 12‐17 years old, 57.3% were female, and 86.6% 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% 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 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).ConclusionsAmong 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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Section: Discussionsupporting

confidence: 84%

Characteristics of pediatric behavioral health emergencies in the prehospital setting

Wnorowska,

Naik,

Ramgopal

et al. 2023

Academic Emergency Medicine

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“…Interviews were conducted between May and August 2022 at the Children's Hospital of Philadelphia. This 594‐bed freestanding children's hospital has a 10‐bed Medical Behavioral Unit (MBU), which is a medical unit with enhanced behavioral supports, a 20‐bed adolescent medicine unit offering medical management of eating disorders, and four emergency department (ED) psychiatric triage beds 17 . While there is no inpatient psychiatric unit, 4% of annual admissions are children hospitalized for boarding who receive daily assessment by a mental health clinician while awaiting psychiatric disposition.…”

Section: Methodsmentioning

confidence: 99%

“…which is a medical unit with enhanced behavioral supports, a 20-bed adolescent medicine unit offering medical management of eating disorders, and four emergency department (ED) psychiatric triage beds. 17 While there is no inpatient psychiatric unit, 4% of annual admissions are children hospitalized for boarding who receive daily assessment by a mental health clinician while awaiting psychiatric disposition. Approximately 26% of hospitalized children report a comorbid mental health condition; these patients receive care on general medical units with as-needed psychiatric support.…”

Section: Methodsmentioning

confidence: 99%

Factors influencing agitation, de‐escalation, and physical restraint at a children's hospital

Dalton

Worsley

Krass

et al. 2023

Journal of Hospital Medicine

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Background Children hospitalized in medical hospitals are at risk of agitation. Physical restraint may be used to maintain patient and staff safety during de‐escalation, but physical restraint use is associated with physical and psychological adverse events. Objective We sought to better understand which work system factors help clinicians prevent patient agitation, improve de‐escalation, and avoid physical restraint. Design, Setting, and Participants We used directed content analysis to extend the Systems Engineering Initiative for Patient Safety model to clinicians working with children at risk for agitation at a freestanding children's hospital. Intervention, Main Outcome, and Measures We conducted semistructured interviews to examine how five clinician work system factors affected patient agitation, de‐escalation, and restraint: person, environment, tasks, technology and tools, and organization. Interviews were recorded, transcribed, and analyzed until saturation. Results Forty clinicians participated in this study, including 21 nurses, 15 psychiatric technicians, 2 pediatric physicians, 1 psychologist, and 1 behavior analyst. Work system factors that contributed to patient agitation were medical tasks like vital signs and the hospital environment including bright lights and neighboring patients' noises. Supports that helped clinicians de‐escalate patients included adequate staffing and accessible toys and activities. Participants indicated that organizational factors were integral to team de‐escalation, drawing connections between units' teamwork and communication cultures and their likelihood of successful de‐escalation without the use of physical restraint. Conclusion Clinicians perceived that medical tasks, hospital environmental factors, clinician attributes, and team communication influenced patients' agitation, de‐escalation, and physical restraint. These work system factors provide opportunities for future multi‐disciplinary interventions to reduce physical restraint use.

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“…11 Patients boarding on inpatient units may exhibit aggression and agitation due to underlying psychiatric conditions, an unfamiliar environment, or increased stimulation. 12,13 A survey of pediatric hospitalists found 20% of providers managed acute agitation and behavioral escalation more than once per week, and 34% three times a month. 14 Aggression and agitation may lead to safety concerns for the patient and staff necessitating physical and/or pharmacologic restraints.…”

Section: Introductionmentioning

confidence: 99%

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals

Wolf

Hall

Williams

et al. 2022

Journal of Hospital Medicine

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Background: Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use. Objective: To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals. Design, Setting, and Participants: We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared.Results: Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis.Conclusions: Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

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Patient Risk Factors for Violent Restraint Use in a Children’s Hospital Medical Unit

Cited by 10 publications

References 21 publications

Characteristics of pediatric behavioral health emergencies in the prehospital setting

Characteristics of pediatric behavioral health emergencies in the prehospital setting

Factors influencing agitation, de‐escalation, and physical restraint at a children's hospital

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals

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