Children who are male, Black more likely to experience pharmacologic restraint in ED
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Children with mental or behavioral health conditions are more likely to experience pharmacologic restraint in the ED if they are young, male or Black, according to a study published in Pediatrics.
Co-author Ashley A. Foster, MD, assistant professor of emergency medicine at the University of California, San Francisco School of Medicine, told Healio that many of the study’s researchers work in pediatric EDs and “have witnessed first-hand the increase in emergency department utilization by children with mental and behavioral health conditions.”
“This vulnerable population experiences challenges to care, including prolonged length of emergency department stays while awaiting psychiatric inpatient placement,” Foster said. Along with Joel D. Hudgins, MD, MPH, Foster “led a quality initiative aimed at reducing restraint use within the emergency department.”
“As part of this initiative, we realized there was a dearth of literature regarding trends in restraint use and risk factors for restraint use, both of which could guide the quality intervention,” Foster said.
The researchers analyzed the Pediatric Health Information System database — which contains data from up to 49 not-for-profit tertiary care pediatric hospitals in the U.S. — focusing on data from ED visits for children aged 3 to 21 years who were placed under pharmacologic restraint, defined as “intramuscular or intravenous administration of a specific grouping of medications,” Foster said.
They then determined hospital-level use of pharmacologic restraint by sorting based on average annual mental and behavioral health visits and average annual volume.
Out of 545,800 ED visits relating to mental and behavioral health, 22,194 visits (4.1%) involved the use of pharmacologic restraint.
Their examination found that children with mental or behavioral health conditions were more likely to experience pharmacologic restraint if they were aged 18 through 21 years old (OR, 1.88; 95% CI, 1.59-2.22), male (OR, 1.25; 95% CI, 1.16-1.34), Black (OR, 1.22; 95% CI, 1.09-1.35), visited during overnight hours (OR, 1.68; 95% CI, 1.44-1.96) or on the weekend (OR, 1.26; 95% CI, 1.22-1.30) or had repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47).
“Since previous literature has reported racial disparities in physical restraint use in children in the emergency department, we were not surprised by the results but concerned to see this as an association with pharmacologic restraint,” Foster said. “The associations of pharmacologic restraint with visits starting on the weekend and overnight hours were also illuminating and provide an opportunity to further explore how emergency department factors may impact patient care.”
The researchers also found that every 100-visit increase in average annual volume of mental and behavioral health visits at the hospitals was associated with a 0.09% decrease in restraints (95% CI, –0.15 to –0.04); without significant association between average annual ED volume and restraint (95% CI, –0.25 to 0.25).
“The inverse relationship between average annual mental and behavioral health visits and pharmacologic restraint was unexpected,” Foster said. “Our hypothesis is that emergency departments that have larger annual volumes of patients with mental and behavioral health conditions may have more dedicated physical resources, specialty staffing, and staff comfort with identifying agitation and utilizing de-escalation strategies.”
Foster also said that the findings add to a “growing body of literature that report disparities in care for children with mental and behavioral health conditions,” and that “continued identification of potential disparities and advocacy for standardization of care may help to improve outcomes for all children with mental and behavioral health conditions.”
“I think there would be significant value in conducting research on validating an agitation screening tool and validating a standardized agitation clinical care pathway for children in the emergency department,” Foster said. “These tools could then be studied to understand if both restraint reduction and more equitable care can be achieved. Additionally, further study of emergency departments with low and high restraint rates may help to uncover factors that contribute to variation in care.”