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Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP—or Child and Adolescent Psychiatry—Smart Take, we will look closely at disparities in the use of pharmacologic restraints in pediatric emergency departments. Now, we know that emergency department use by children with mental and behavioral conditions is skyrocketing, not uncommonly resulting in boarding in the emergency department and extended stays. Many families in our pediatric emergency department use the emergency room as their primary site for addressing behavioral and mental health conditions and concerns. This is not surprising in a complex and often challenging mental health system that is all too often overwhelmed and understaffed. Decreased inpatient psychiatry beds in the community further complicate and challenge pediatric emergency departments with extended stays of youth with behavioral and mental health conditions.
So, in this multicenter study described by Foster and colleagues, emergency department visits from over 540,000 youth with a primary mental or behavioral diagnosis of 3–21 years of age were analyzed between 2010–20. Over 22,000 visits, or just over 4%, involved pharmacologic restraint. Pharmacologic restraint was predicted with ages 18–21 years, male sex, Black race, visits starting during the weekend or overnight when staffing is usually less intense, and repeat visits for mental or behavioral health conditions. Interestingly, pharmacologic restraint decreased as the average annual emergency department volume of youth with mental or behavioral health conditions increased. This may be due to emergency departments with more patients with mental or behavioral conditions. They may get more experience, dedicate more resources to these patients, and become more comfortable handling behavioral and mental health patients in the emergency department.
Now, the authors of this article also did a deep dive and took a close look at potential healthcare disparities in pharmacological restraint. They found that Black patients were significantly more likely to have pharmacologic restraint than White patients. This is very important and raises many questions about possible biases resulting from explicit or implicit bias. Moreover, it also raises opportunities for quality improvement using standardized protocols and various quality improvement initiatives to ensure that all patients are treated the same, or at least in the same manner, that can minimize the risk of these racial or ethnic disparities.
Although we have focused primarily on pharmacologic restraint, there are behavioral interventions that can significantly decrease the need for pharmacologic restraint. This includes staff training in how to react to youth and their families and to be proactive rather than reactive in terms of intervening before the situation gets out of control regarding agitation and aggression. Our department has developed what we call a Compassionate Care Training Program where we train nonmental health personnel and emergency departments, as well as medical and surgical inpatient units, outpatient clinics, group homes, and more, on how to assess better and be alert for behavioral dyscontrol, and which strategies can be used to prevent or reduce its occurrence. Part of this may involve decreasing external stimuli around an agitated patient, being attentive, checking back in with patients and families, and identifying families who seem upset or children, adolescents, and families who are nervous and have been asking for more information.
The Compassionate Care Training we developed is a behavioral analog to ACLS with vignettes, role play, and interactive training to become more comfortable and adept when interacting with patients with mental and behavioral health conditions. We would not expect a physician with no training at all to go in and do advanced cardiac life support. Similarly, in psychiatric behavioral dyscontrol in an emergency room setting—sometimes unexpected, sometimes with decreased resources—we should not expect that someone with no training in the behavioral aspects would be able to walk in and do things perfectly.
My experience or postmortems about agitation and aggression in our work convinces me that many pharmacologic restraints are preventable. Now, there is no doubt that some are not, and even with the best care, pharmacologic restraint is necessary. However, pharmacologic restraint can often be prevented or minimized if the right behavioral policies are in place and people are trained to be proactive rather than reactive. Moreover, some aspects can be straightforward. For example, I am a child and adolescent psychiatrist. Can you guess the one word I never use with my pediatric patients? I will give you a hint: It is 1 syllable. The word is “no” because it immediately changes the dynamic when I say no to a child or adolescent. This does not mean I agree and do whatever the child or adolescent wants—quite the contrary.
However, rather than starting with no and getting the adolescent or child in a defensive posture, where there is immediately some confrontation, I like to take that away, show the person that I am listening to them, and that I realize their concerns are valid, do what I can to bond with a particular child. This does not mean it always works and you can bond with every adolescent or child. However, in my experience, this can be quite successful and can often defuse certain opposition and concerns in children or adolescents. I am letting them know that I hear their concerns. I want to address them. I want to look for ways to ally. Much of the training in terms of compassionate care is far more complex than just not saying the word no.
However, the principle is the same: To retrain the brain, to retrain our limbic system in terms of emotions and how we process emotions, and to think proactively about approaches and how to keep everyone safe, prevent, minimize, and be ready and not unprepared for aggression or agitation. The bottom line is that this is an important early paper reflecting a growing national epidemic of skyrocketing youth visits to the emergency department for mental health and behavioral conditions. The healthcare disparities are meriting attention, and we are training in implicit and explicit bias and developing standardized protocols, which may help significantly reduce these biases.
Abstract
Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments
Ashley A Foster, John J Porter, Michael C Monuteaux, Jennifer A Hoffmann, Joyce Li, Lois K Lee, Joel D Hudgins
Objectives: Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described.
Methods: This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint.
Results: Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25).
Conclusions: For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.
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Reference
Foster, A. A., Porter, J. J., Monuteaux, M. C., Hoffmann, J. A., Li, J., Lee, L. K., & Hudgins, J. D. (2023).
Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments
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Pediatrics, 151
(1), e2022056667.
