178 Behavioral Emergencies, Involuntary Holds, and Restraint Use Among Pediatric Patients Transported by Emergency Medical Services in Alameda County, 2011-2016

Abstract

Emergency department (ED) visits for behavioral emergencies are common in the United States, and approximately 74% arrive by ambulance. However, national datasets provide little insight into details of out-of-hospital management of these emergencies. In Alameda County, CA, police and EMS respond to most behavioral health crises. Although ambulances transport most children to a general ED for medical clearance, Alameda County EMS workers use a screening protocol to identify a subset of children over age 12 that may be directly transported to a pediatric psychiatric emergency service. We aimed to describe the patients, visits, and safety outcomes associated with these behavioral emergency ambulance encounters. We obtained data for all pediatric (age<18) EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County’s standardized data set. After unique patient identification and linkage to data from Alameda County Vital Statistics, we describe the dataset at the patient level and at the encounter level. During the study period, EMS treated 29,123 unique patients, and 17.2 % (N=5,022) had at least one behavioral emergency. 554 patients were transported 3 or more times, and accounted for 35% (N=2,771) of all behavioral emergency encounters. There were 6 deaths (0.1%) among children transported for at least one behavioral emergency, but none were within 60 days of a visit for a behavioral emergency. The median age for a behavioral health emergency was 15.1 (IQR: 13.1 - 16.6). There were a total of 37,888 total EMS encounters, and 21.0% (N=7,938) were for behavioral emergencies, making them the second most common reason for ambulance transport after traumatic injuries (25.1%, N=9,506). Behavioral emergencies frequently occured at home (44.4%), at school (30.8%), and in a number of other public places (24.9%). Overall, 6.9% of children were placed in handcuffs by police prior to EMS arrival, and 15.3% of patients were placed in physical restraints during transport. Behavioral emergency transports originating at school resulted in a lower rate of physical restraint placement by EMS (9.0%) as compared to those originating at home (15.6%, RR: 1.7, 95% CI: 1.5 - 2.0) or in other public locations (22.5%, RR: 2.5, 95% CI: 2.1 - 2.9).2,941 (37.0%) behavioral emergency encounters met protocol criteria and were transported directly to the pediatric psychiatric emergency service. From a safety perspective, only 13 (0.4%) patients had a secondary transport to a general ED within 12 hours of arrival to the psychiatric facility. None of these patients required any critical EMS intervention. Behavioral health emergencies are the second most common reason for transport of pediatric patients. Direct transportation to a pediatric psychiatric emergency service is safe, and the need for general ED transport for all patients is likely unnecessary. Even in the long-term, death is rare in pediatric patients after EMS transport for a behavioral emergency. Use of handcuffs and restraints by police and EMS is common, but varies based on the location in which the emergency occurred. Further research should be conducted to better understand the out-of-hospital management of pediatric behavioral emergencies.