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

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.

De-escalation Techniques for the Agitated Pediatric Patient

“…Pediatric patients may become agitated in any health care setting; however, acute agitation is encountered frequently in the emergency department (ED) 1–3 . The increasing prevalence of childhood mental health conditions in the United States has led to a significant increase in the number of visits to EDs for psychiatric-related concerns 4 .…”

“…Restraints should be used only as a last resort to ensure the immediate safety of the patient, staff, or others after less-restrictive strategies have failed 16,37 . Despite this recommendation, which is endorsed by multiple organizations including the Substance Abuse and Mental Health Services Administration and the American Association for Emergency Psychiatry, restraint use has been increasing over time 3,38 . Restraints can cause psychological distress and retraumatization, increase risk of serious injury to patients and staff, and have even resulted in death 39,40 .…”

Emergency Department Restraint Safety

“…A provider must have a plan to address and manage the agitated patient. Therefore, issues regarding restraint utilization are a commonplace challenge in the ED given the wide range and continual change in patient populations [5,15,16]. However, why are agitated and violent presentations so prevalent and trending upward?…”

Physical Restraint Use in the Pediatric Emergency Department

“…Behavioral health visits also have increased length of stay, with many patients boarding in the PEDs due to lack of resources within the community. 2,6,7 As many patients are likely to remain in the PED for a longer period, it is important that staff are well educated and comfortable caring for these patients, especially the ones that become agitated/aggressive, as this can lead to a disruption in care as well as significant injury to both the staff and patient. This is especially true when considering that most ED environments are often noisy and overstimulating with rooms not adequately set up to help this patient population remain calm during long lengths of stay.…”

“…This is especially true when considering that most ED environments are often noisy and overstimulating with rooms not adequately set up to help this patient population remain calm during long lengths of stay. 2 Unfortunately, there is an overall lack of physician education related to restraint choice/use and resources related to de-escalation and other preventative strategies. 8,9 Until recently, there was also a lack of consensus on how to care for these pediatric patients.…”