Pharmacologic Management of Acute Agitation in Youth in the Emergency Department

Hoffmann, Jennifer A.; Pergjika, Alba; Konicek, Claire E.; Reynolds, Sally

doi:10.1097/pec.0000000000002510

Cited by 18 publications

(42 citation statements)

References 26 publications

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“…Based on this study, the prevalence of acute agitation and restraint use were 13.8% and 28.8%, respectively, implying that more than twothirds of acutely agitated patients were managed with established de-escalation strategies such as effective communication, environmental modifications, and behavioral interventions by our multidisciplinary collaborative team. 4,6,25 The true prevalence of pediatric acute agitation remains unknown despite prior attempts to extrapolate this prevalence from the rate of restraint use in the acute care setting. 18,26 This is because such inferential statistics generally underestimate the true prevalence of pediatric agitation due to significant selection bias by severity.…”

Section: Discussionmentioning

confidence: 99%

“…4,5 Acute agitation can result in significant care disruption, property destruction, and unnecessary resource use. 6 Therefore, anticipation, prompt recognition, and early intervention are needed to avoid significant injuries and process disruption from behavioral escalation. 6 Typically, a child with mental and behavioral health (MBH) needs may present to the emergency department (ED) acutely agitated or become agitated while in the ED.…”

Section: Introductionmentioning

confidence: 99%

“…6 Therefore, anticipation, prompt recognition, and early intervention are needed to avoid significant injuries and process disruption from behavioral escalation. 6 Typically, a child with mental and behavioral health (MBH) needs may present to the emergency department (ED) acutely agitated or become agitated while in the ED. The standard ED setting is not well suited for the mentally ill or agitated patient.…”

Section: Introductionmentioning

confidence: 99%

“…The agitated child or adolescent poses a significant risk to self, staff, parent(s), and others 4,5 . Acute agitation can result in significant care disruption, property destruction, and unnecessary resource use 6 . Therefore, anticipation, prompt recognition, and early intervention are needed to avoid significant injuries and process disruption from behavioral escalation 6 …”

Section: Introductionmentioning

confidence: 99%

“… 6 Therefore, anticipation, prompt recognition, and early intervention are needed to avoid significant injuries and process disruption from behavioral escalation. 6 …”

Section: Introductionmentioning

confidence: 99%

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The agitated pediatric patient located in the emergency department: The APPLIED observational study

et al. 2022

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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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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“… 6 Therefore, anticipation, prompt recognition, and early intervention are needed to avoid significant injuries and process disruption from behavioral escalation. 6 …”

Section: Introductionmentioning

confidence: 99%

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The agitated pediatric patient located in the emergency department: The APPLIED observational study

et al. 2022

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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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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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Pharmacologic Management of Acute Agitation in Youth in the Emergency Department

Cited by 18 publications

References 26 publications

The agitated pediatric patient located in the emergency department: The APPLIED observational study

The agitated pediatric patient located in the emergency department: The APPLIED observational study

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

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

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