De-escalation Techniques for the Agitated Pediatric Patient

Demographic Perspectives and De-escalation Challenges in Pediatric Emergency Care for Children with Special Health Care Needs

Introduction

Medical literature on emergency care for children with special healthcare needs (SHCNs) reports the inherent challenges in the managing of these children, like limited history, distress for patients and families, and unique management requirements for healthcare teams. This study analyzed the demographic data on children with SHCNs to explore de-escalation strategies, the effectiveness of chemical de-escalation, and clinical management strategies used and compared the length of stay in the emergency department (ED) between patients who received medications and those who did not.

Methods

This was a retrospective and cross-sectional study. Data were collected from the last 150 patients diagnosed with SHCNs across three ED s within this hospital system since July 1, 2023. Children aged 18 years or younger diagnosed with SHCNs requiring special modifications. Chi-square test, Mann-Whitney U-test, and Kruskal-Wallis H-test.

Results

The demographic analysis showed that 60% of children with SHCNs were female, with a mean age of 12.3 years. The most common presentation time was 6-8 pm. autism spectrum disorder (28%) and anxiety disorder (27%) were the most frequent diagnoses, with substance abuse present in 45% of patients. Medications helped reduce the ED stay, which was statistically significant, suggesting that medications may facilitate effective de-escalation; At the same time, in a few cases, verbal de-escalation also appeared helpful. There is a need for robust documentation on verbal de-escalation strategies, such as details on patients who did not receive medications and were successfully managed verbally or required repeated reassurance.

Conclusions

This study provides insight into the diverse challenges of managing children with SHCNs in the emergency settings. The high prevalence of substance abuse, particularly in children with autism spectrum, increases the complexity of care. While medications may reduce ED stay, further research is needed to understand this patient population's complex needs better.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Strategies for optimal management of pediatric acute agitation in emergency settings

Acute agitation in youth is a challenging presentation to the emergency department. In many cases, however, youth can be behaviorally de-escalated using a combination of environmental modification and verbal de-escalation. In cases where additional strategies such as pharmacologic de-escalation or physical restraint are needed, using the least restrictive means possible, including the youth in the decision-making process, and providing options are important. This paper reviews specific considerations on the approach to a youth with acute agitation and strategies and techniques to successfully de-escalate agitated youth who pose a danger to themselves and/or others.

Approach to acute agitation in the pediatric emergency department

PURPOSE OF REVIEW

The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED.

RECENT FINDINGS

Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time.

SUMMARY

Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children With Mental and Behavioral Health Conditions in the Emergency Department

BACKGROUND

Mental health visits to the emergency department (ED) by children are rising in the United States, and acute agitation during these visits presents safety risks to patients and staff.

OBJECTIVE

We sought to assess barriers and strategies for providing high-quality care to children who experience acute agitation in the ED.

METHODS

We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their experiences with acute agitation care in the ED, barriers and facilitators to providing high-quality care, and proposed interventions. Interviews were coded and analyzed thematically.

RESULTS

Participants discussed identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture toward patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities.

CONCLUSIONS

Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.