Use Of Restraints Research Articles

Physicians' beliefs and perceived importance of traumatic brain injury-associated agitation in critically ill patients: a survey of Canadian intensivists.

Agitation is a common behavioural problem following traumatic brain injury (TBI). Intensive care unit (ICU) physicians' perspectives regarding TBI-associated agitation are unknown. Our objective was to describe physicians' beliefs and perceived importance of TBI-associated agitation in critically ill patients. Following current standard guidance, we built an electronic, self-administrated, 42-item survey, pretested it for reliability and validity, and distributed it to 219 physicians working in 18 ICU level-1 trauma centres in Canada. We report the results using descriptive statistics. The overall response rate was 93/219 (42%), and 76/93 (82%) respondents completed the full survey. Most respondents were men with ten or more years of experience. Respondents believed that pre-existing dementia (90%) and regular recreational drug use (86%) are risk factors for agitation. Concerning management, 91% believed that the use of physical restraints could worsen agitation, 90% believed that having family at the bedside reduces agitation, and 72% believed that alpha-2 adrenergic agonists are efficacious for managing TBI agitation. Variability was observed in beliefs on epidemiology, sex, gender, age, socioeconomic status, and other pharmacologic options. Respondents considered TBI agitation frequent enough to justify the implementation of management protocols (87%), perceived the current level of clinical evidence on TBI agitation management to be insufficient (84%), and expressed concerns about acute and long-term detrimental outcomes and burden to patients, health care professionals, and relatives (85%). Traumatic brain injury-associated agitation in critically ill patients was perceived as an important issue for most ICU physicians. Physicians agreed on multiple approaches to manage TBI-associated agitation although agreement on epidemiology and risk factors was variable.

Restraint use within vehicles transporting child occupants in Dubai, United Arab Emirates: An observational study

ObjectiveThis observation study aimed to describe the frequency and type of restraint use for child occupants within private motor vehicles in the emirate of Dubai in the United Arab Emirates (UAE). MethodsAn overt, on-road observation study was conducted by trained observers who recorded the restraint use of the occupants while travelling in private motor vehicles with at least one child aged approximately ten years and younger in Dubai. ResultsOverall, 2000 vehicles were observed transporting 2940 child occupants estimated to be aged 10 years and younger. Over one-half of the drivers were observed to be using their seatbelt (60.0%) and over one-half of front-seat passengers were observed to be using their seatbelt (53.3%). One-half of the observed child occupants were unrestrained (51.7%), and a further 8.3 percent were seated unrestrained on an adult's lap. Based on the seating position and restraint type within the vehicle, child restraint use was classified into appropriate, seatbelt and inappropriate use, and the results showed that more than one-half of the child occupants were inappropriately restrained (59.9%). There was a significant relationship between the driver's seatbelt use and inappropriate restraint use for at least one child occupant in the vehicle (χ2 (1) = 75.450, p < 0.001). Unrestrained drivers were more likely to have at least one inappropriately restrained child in their vehicle (28.4%) than to have all children appropriately restrained (8.8%). ConclusionsDespite the introduction of child restraint system (CRS) legislation in 2017 that mandated the use of CRS for child occupants aged four years and younger while travelling in a private motor vehicle in the UAE, this study observed a high proportion of unrestrained or inappropriately restrained child occupants than expected. These findings highlight an urgent need for greater enforcement of this legislation and awareness programs about the significant injury risks for unrestrained or inappropriately restrained child occupants in the UAE.

Nurses Knowledge and Performance Toward Physical Restraint at Critical Care Units

Abstract:&#x0D; Objective: The study was done to evaluate nurses’ knowledge and practices toward physical restraint at critical care unit&#x0D; Methodology: Fifty nurses, who were selected by a non-probability (convenient) sampling method, participated in this descriptive study. The instrument of the study was knowledge parts of the questionnaire were initially developed in the U.S.A for nursing homes; in 2006 they were adopted for all hospital units by the original developers. The knowledge section of the questionnaire consisted of 20 items, which were used to measure knowledge of nurses towards the definition, indications and contraindications, proper application and legal and ethical considerations of physical restraint use. A three- point ordinal scale (Agree, Uncertain and Disagree) was applied to determine nurses’ responses to the items; it contained negative and positive sentences. Positive items, if answered with “agree,” were considered correct; if answered with “disagree,” items were considered incorrect. To evaluate the nurse's practices with respect to physical restraint, the researcher observes and checks for correct or incorrect performance. The practices checklist for nurses is composed of (94) items divided into six content domains.&#x0D; Results: The result of this research showed that 90% of nurses had low knowledge about physical restraint, and 80 % of the participants had unsatisfactory performance.&#x0D; Recommendation: The study recommended development of local policies for physical restraint use including detailed descriptions of conditions requiring its use is mandatory.&#x0D; Key words- Knowledge, Performance, Physical Restraint, Critical Care Units

A country report: impact of COVID-19 lockdowns on involuntary psychiatric treatment in Austria.

Coercive measures such as involuntary psychiatric admission are considered a last resort in the treatment of people with psychiatric disorders. So far, numerous factors have been identified that influence their use. However, the link between a pandemic - in particular, restrictions such as lockdowns - and the use of involuntary psychiatric admission is unclear. To examine the association between COVID-19 lockdowns and involuntary psychiatric admissions in Austria. This retrospective exploratory study assessed all involuntary psychiatric admissions and use of mechanical restraint in Austria, except for the federal state of Vorarlberg, between 1 January 2018 and 31 December 2020. Descriptive statistics and regression models were used. During the 3-year study period, 40 012 individuals (45.9% females, mean age 51.3 years) had 66 124 involuntary psychiatric admissions for an average of 10.9 days. Mechanical restraint was used during 33.9% of these admissions. In weeks of nationwide COVID-19 lockdowns (2020 v. 2018/2019), involuntary psychiatric admissions were significantly fewer (odds ratio = 0.93, P = 0.0001) but longer (11.6 (s.d.: 16) v. 10.9 (s.d.: 15.8) days). The likelihood of involuntary admission during lockdowns was associated with year (2020 v. 2018-2019; adjusted odds ratio = 0.92; P = 0.0002) but not with sex (P = 0.814), age (P = 0.310), use of mechanical restraint (P = 0.653) or type of ward (P = 0.843). Restrictions such as lockdowns affect coercive measures and resulted in fewer but longer involuntary psychiatric admissions during weeks of lockdown in Austria. These results strengthen previous findings that showed the dependence of coercive measures on external factors, highlighting the need to further clarify causality and desired prevention effects when using coercive measures.

Physical and Pharmacologic Restraint in Hospitalized Children With Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) have high rates of cooccurring conditions and are hospitalized longer and more frequently than children without ASD. Little is known about use of involuntary physical or pharmacologic restraint in hospitalized children with ASD. This study compares use of restraint because of violent or self-injurious behavior during inpatient pediatric hospitalization in children with ASD compared with typical peers. This retrospective cohort study examines electronic health records of all children aged 5 to 21 years admitted to a pediatric medical unit at a large urban hospital between October 2016 and October 2021. Billing diagnoses from inpatient encounters identified ASD and cooccurring diagnoses. Clinical orders identified physical and pharmacologic restraint. Propensity score matching ensured equivalency between ASD and matched non-ASD groups on demographic factors. Logistic regression determined the odds of restraint in children with ASD compared with children without ASD, controlling for hospitalization factors and cooccurring diagnoses. Of 21 275 hospitalized children, 367 (1.7%) experienced restraint and 1187 (5.6%) had ASD. After adjusting for reason for admission, length of stay, and cooccurring mental health, developmental, and behavioral disorders, children with ASD were significantly more likely to be restrained than children without ASD (odds ratio 2.3, 95% confidence interval 1.6-3.4; P < .001). Hospitalized children with ASD have significantly higher odds of restraint for violent or self-injurious behavior compared with children without ASD after accounting for reason for admission, length of hospitalization and cooccurring diagnoses. Work is needed to modify the hospital environment for children with ASD to reduce behavioral dysregulation and restraint.

Pharmacologic Restraint Use During Mental Health Admissions to Children's Hospitals.

Primary mental health admissions are increasing across US children's hospitals. These patients may experience agitation requiring pharmacologic restraint. This study characterized pharmacologic restraint use in medical inpatient units by primary mental health diagnosis. This retrospective, cross-sectional study used the Pediatric Health Information System database. The study included children aged 5 to 17 years admitted with a primary mental health diagnosis between 2016 and 2021. Rates of pharmacologic restraint use per 1000 patient days were determined for 13 mental health diagnoses and trended over time with Poisson regression. Of 91 898 hospitalizations across 43 hospitals, 3% of admissions and 1.3% of patient days involved pharmacologic restraint. Trends in the rate of pharmacologic restraint use remained stable (95% confidence interval [CI], 0.7-2.1), whereas the incidence increased by 141%. Diagnoses with the highest rates of pharmacologic restraint days per 1000 patient days included autism (79.4; 95% CI, 56.2-112.3), substance-related disorders (45.0; 95% CI, 35.9-56.4), and disruptive disorders (44.8; 95% CI, 25.1-79.8). The restraint rate significantly increased in disruptive disorders (rate ratio [RR], 1.4; 95% CI, 1.1-1.6), bipolar disorders (RR, 2.0; 95% CI, 1.4-3.0), eating disorders (RR, 2.4; 95% CI, 1.5-3.9), and somatic disorders (RR, 4.2; 95% CI, 1.9-9.1). The rate significantly decreased for autism (RR, 0.8; 95% CI, 0.6-1.0) and anxiety disorders (RR, 0.3; 95% CI, 0.2-0.6). Pharmacologic restraint use among children hospitalized with a primary mental health diagnosis increased in incidence and varied by diagnosis. Characterizing restraint rates and trends by diagnosis may help identify at-risk patients and guide targeted interventions to improve pharmacologic restraint utilization.

Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis.

Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children's hospitals. We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity. The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72-0.92), Asian (aOR, 0.82; 95% CI, 0.68-0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57-0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49-0.68), except for Hispanic males, and not found in females (aORs, 0.83-0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47-0.91). Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.

A multicomponent intervention program to Prevent and Reduce AgItation and phySical rEstraint use in the ICU (PRAISE): study protocol for a multicenter, stepped-wedge, cluster randomized controlled trial

BackgroundPhysical restraints remain to be commonly used in agitated intensive care unit (ICU) patients worldwide, despite a lack of evidence on efficacy and safety and reports of detrimental short and long-term consequences, such as prolonged delirium and a longer ICU length of stay. Physical restraint minimization approaches have focused mainly on educational strategies and other non-pharmacological interventions. Combining these interventions with goal-directed light sedation therapy if needed may play an important contributory role in further reducing the use of physical restraints. The aim of the study is to determine the effectiveness of a multicomponent intervention (MCI) program, combining person-centered non-pharmacological interventions with goal-directed light sedation, compared to physical restraints.MethodsA multicenter stepped-wedge cluster randomized controlled trial will be conducted in six Dutch ICUs. A power calculation based total of 480 (expected to become) agitated adult patients will be included in 26 months with a subsequent 2-year follow-up. Patients included in the control period will receive standard care with the current agitation management protocol including physical restraints. Patients included in the intervention period will be treated with the MCI program, consisting of four components, without physical restraints: education of ICU professionals, identification of patients at risk for agitation, formulation of a multidisciplinary person-centered care plan including non-pharmacological and medical interventions, and protocolized goal-directed light sedation using dexmedetomidine. Primary outcome is the number of days alive and outside of the ICU within 28 days after ICU admission. Secondary outcomes include length of hospital stay; 3-, 12-, and 24-month post-ICU quality of life; physical (fatigue, frailty, new physical problems), mental (anxiety, depression, and post-traumatic stress disorder), and cognitive health; and 1-year cost-effectiveness. A process evaluation will be conducted.DiscussionThis will be the first multicenter randomized controlled trial determining the effect of a combination of non-pharmacological interventions and light sedation using dexmedetomidine compared to physical restraints in agitated ICU patients. The results of this study, including long-term patient-centered outcomes, will provide relevant insights to aid ICU professionals in the management of agitated patients.Trial registrationNCT05783505, registration date 23 March 2023.

Reducing seclusion and restraint in an acute adolescent psychiatric ward: A feasibility study.

Restraining and secluding health consumers for safety reasons continue to be used in psychiatric inpatient facilities even though they have no therapeutic value and have negative effects on consumers, families and staff. Six Core Strategies (6CS) for reducing seclusion and restraint have been developed to address this problem but there are very few effectiveness studies in inpatient adolescent psychiatric facilities. We used a mixed methods approach to evaluate the implementation of 6CS in an adolescent psychiatric facility. The implementation was successful. It eliminated the use of seclusion, substantially reduced the use of restraints and significantly reduced staff absenteeism. Using thematic analysis on feedback surveys, we identified five dominant themes that described consumers' and carers' experiences during their stay at the facility: communication, service delivery, flexibility, consistency and internal feeling states. This study provides support for the feasibility of a comprehensive and broad-based intervention program such as 6CS to reduce seclusion and restraint practices in inpatient mental health facilities. This study also demonstrates the value of using surveys to gather consumer and carer feedback and improve outcomes for service users. Introduction Seclusion and restraint practices are routinely used in psychiatric facilities but are controversial for ethical, legal and safety reasons, and can cause significant harm to consumers, staff and organisations. Six Core Strategies (6CS) for reducing seclusion and restraint were developed to address this problem but very few studies have examined their effectiveness in adolescent settings. Aim/Question To evaluate the implementation of 6CS in an adolescent inpatient psychiatric facility. Method We retrieved archival data from an acute adolescent psychiatric ward that implemented the 6CS. Using a mixed methods approach, we evaluated outcomes on the use of seclusion and restraint, nursing staff sick leave and feedback surveys. Results Findings showed an elimination of seclusion, and a significant reduction in restraint use and staff absenteeism in the 12 months after project implementation. Thematic analysis of feedback survey responses identified communication, service delivery, flexibility, consistency and internal feeling states as dominant themes in consumers' and carers' experience on the unit. Discussion The 6CS is feasible and may be effective in reducing seclusion and restraint, which in turn may have a positive impact on staff wellbeing. Implications for Practice Implementation of the 6CS with executive support, combined with staff and programmatic changes at a local level is recommended.

Dosage Forms Suitability in Pediatrics: Acceptability of Antibiotics in a German Hospital.

Although drug acceptability can have a significant impact on patient adherence in pediatric therapy, data are limited, even for common therapeutic areas. We present the second part of an acceptability study conducted at the University Children's Hospital Düsseldorf, Germany. The study investigated the acceptability of most commonly used antibiotics in a pediatric hospital setting. The researchers used the acceptability reference framework to score the acceptability of five antibiotics based on 150 real-life observer reports of medicine intake. Four antibiotics assessed in this study were formulated as preparations for injection (ampicillin, ampicillin/sulbactam, ceftriaxone, and gentamicin) and one as a powder for oral liquid suspension (co-amoxiclav). All the antibiotics formulated as preparations for injection were rated negatively due to high rates of negative reactions (80%), the use of restraint (51%), the use of extra devices (99%), and long preparation and administration times (100%). The antibiotic formulated as a powder was significantly more well accepted. The study concluded that there is a lack of appropriate formulations for antibiotics for use in children. These findings are important in improving knowledge on acceptability drivers and might help in formulating and prescribing better medicines for children. The study highlights the need for healthcare professionals to have knowledge about the acceptability of different products to select the best-adapted product for each patient.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department

IntroductionRestraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation– a standardized, team-based approach for management and assessment of threatening behaviors– in reducing physical restraint use and workplace violence in a community ED. MethodsA retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. ResultsPre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002–0.055], p < 0.05). This was not seen at the control sites. ConclusionsA standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Patient‐related factors and mortality associated with nasogastric tube feeding in advanced dementia

AbstractBackgroundPrevious studies have not shown survival benefit for long‐term enteral feeding. However, these studies were mostly done in residents of nursing homes, where quality of care may vary. Patients cared for in their own home may have more consistent quality of care. The aim of this study is to explore if NGT feeding prolongs life in community‐dwelling PWSDs and if not, what are other factors that may influence survival in PWSDs. Additionally, we wanted to explore patient‐related factors associated with NGT feeding to better understand the patient profile of PWSDs on NGTMethodCommunity‐dwelling PWSDs with a FAST 6c score or higher, were evaluated and followed‐up for a median duration of 25 months as part of the PISCES study, a prospective longitudinal cohort study.Result215 PWSDs were evaluated, 9.8% (n = 21) had NGT at baseline. Compared to those without NGT, PWSDs on NGT were more likely to have had a stroke (66.7% vs 29.9%, p = 0.001), recent pneumonia (28.6% vs 7.2%,p = 0.001), recent oral antibiotics (57.1% vs 26.8%,p = 0.004) and higher Bedford Alzheimer Nursing‐Severity Scale scores(BANS‐S)(22.4 vs 18.2,P = 0.00). Although PWSDs with NGT had lower physical and verbal behavioural problems(P&lt;0.05), there was increased use of restraints (71.4% vs 44.3%,p = 0.018), pressure sores(28.6% vs 10.8%,p = 0.02) and they had poorer Quality of life(QoL) in late‐stage dementia(QUALID) scores (27.8 vs 22.6,p = 0.006), and no difference in malnourishment rate (19% vs 20%, p = 0.865). PWSDs with NGT had no survival benefit (HR 1.42, 95%CI 0.689‐2.91) despite adjustment for significant comorbidities and dementia severity, however BANS‐S and malnourishment predicted mortalityConclusionWhile NGT use in PWSDs does not predict mortality, poorer BANS‐S scores and malnourishment were associated with higher mortality and this may be because they imply more advanced dementia. PWSDs on NGT had more advanced dementia and comorbidities. Increased use of restraints despite lower behavioural problems could have been pre‐emptive to prevent removal of NGT, while the lower QoL scores might be attributed to more advanced dementia and use of NGT with restraints. These findings can help clinicians and families make informed decisions on tube feeding.

Physical Restraint Use within Maltese Long-Term Care Settings

The holistic study looked at the locally unexplored environment, providing a platform of knowledge base and information on physical restraint use. The project secured relevant information focal to the older person residents, health care providers and policy makers within long-term care settings.

Nurses' Opinions About Patient Restraint Methods in a Psychiatric Hospital and Their Ethical Sensitivity

Methods of restraint can be used to prevent hospitalized psychiatric patients from injuring themselves or others, but use of restraints causes various ethical problems in psychiatric nursing. This study examined the relationship between nurses' sociodemographic characteristics, types of restraint methods used, nurses' opinions about those methods, and their level of ethical sensitivity toward their use. We found the moral sensitivity of our participants to be moderate, and statistically significant differences were found related to marital status, shift type, and restraint method used. Based on our results, we recommend improving nurses' working conditions, increasing their level of ethical knowledge, and expanding the number of studies on these issues. [ Psychiatr Ann. 2023;53(12):559–569.]

The association between early diagnosis of dementia and health care utilization in psychiatric hospitalization for behavioral and psychological symptoms

AbstractBackgroundEarly diagnosis of dementia has been considered an effective strategy to reduce the healthcare cost for dementia but not conclusive. Our aim is to examine the association between early diagnosis of dementia and healthcare utilization in the first psychiatric hospitalization for behavioral and psychological symptoms.MethodsThis retrospective cohort study examined whether the diagnosis of dementia before index hospitalization affected healthcare management after the index hospitalization for 1972 elderly individuals between 2005 and 2015, using National Health Insurance claims data in Taiwan. Propensity scores, inverse probability of treatment weighting (IPTW), and regression analyses were used to adjust for confounding and examine the effect of early dementia diagnosis. The outcomes were chemical restraints, physical restraints, and healthcare utilization.ResultsAmong the 1,972 patients, 89.6% had an early diagnosis, and 10.4% had a delayed dementia diagnosis. The delayed dementia diagnosis group was younger and had less comorbidity. IPTW showed that the delayed diagnosis group received more chemical and physical restraints. The length of stay of index hospitalization in the delayed diagnosis group was 8 days longer than the early diagnosis group. Additionally, the delayed diagnosis group had significantly higher total medical expenses by NT$27,344 and higher total drug expenses by NT$1,912 than the early diagnosis group.ConclusionAn early diagnosis of dementia was associated with decreased use of physical and chemical restraints, shortened length of stay of acute hospitalization, and decreased overall healthcare costs in psychiatric hospital admissions compared with a delayed diagnosis.

Application of Light Therapy in Dementia Care

Patients with dementia often display related sleep disturbance, depression, and behavioral and psychological symptoms, which are traditionally managed through the use of antipsychotic medications or physical restraint. However, these management interventions can have negative effects on the physical and psychological health of patients. The results of several meta-analyses suggest non-pharmacological interventions, including light therapy, should be used for the first-line management of these dementia symptoms. Light therapy uses artificial light to compensate for insufficient light exposure during the daytime and to help patients with dementia properly regulate their circadian rhythms. Sleep disturbance and depression in those with dementia may be effectively relieved through the application of light therapy. Nurses should assess the needs and symptoms of patients with dementia and consider applying light therapy as a complementary care intervention to improve quality of care.

Staff wellbeing interventions and its impact on levels of physical intervention in an inpatient unit for individuals with a learning disability: A feasibility study

There is a strong focus nationally on reducing the use of restrictive intervention to manage behaviours that can be described as challenging in people with a learning disability and/or autism. Research has shown that increased staff wellbeing can result in the reduction of these approaches. This study explored the impact of ongoing weekly wellbeing sessions for staff in an NHS inpatient unit for individuals with a learning disability, autism and associated mental health conditions. Baseline data indicated staff were burnt-out and lacked job satisfaction in some but not all areas, although the participants reported high levels of mindfulness awareness. Post-intervention results suggested that the wellbeing sessions had no effect on staff burn-out, job satisfaction or mindfulness awareness. However, the frequency of the use of physical restraints during this time was also collected and results show a reduction in frequency.

EMS Responses for Pediatric Behavioral Health Emergencies in the United States: A 4-Year Descriptive Evaluation.

The occurrence of behavioral health emergencies (BHEs) in children is increasing in the United States, with patient presentations to Emergency Medical Services (EMS) behaving similarly. However, detailed evaluations of EMS encounters for pediatric BHEs at the national level have not been reported. This was a secondary analysis of a national convenience sample of EMS electronic patient care records (ePCRs) collected from January 1, 2018 through December 31, 2021. Inclusion criteria were all EMS activations documented as 9-1-1 responses involving patients < 18 years of age with a primary or secondary provider impression of a BHE. Patient demographics, incident characteristics, and clinical variables including administration of sedation medications, use of physical restraint, and transport status were examined overall and by calendar year. A total of 1,079,406 pediatric EMS encounters were present in the dataset, of which 102,014 (9.5%) had behavioral health provider impressions. Just over one-half of BHEs occurred in females (56.2%), and 68.1% occurred in patients aged 14-17 years. Telecommunicators managing the 9-1-1 calls for these events reported non-BHE patient complaints in 34.7%. Patients were transported by EMS 68.9% of the time, while treatment and/or transport by EMS was refused in 12.5%. Prehospital clinicians administered sedation medications in 1.9% of encounters and applied physical restraints in 1.7%. Naloxone was administered for overdose rescue in 1.5% of encounters. Approximately one in ten pediatric EMS encounters occurring in the United States involve a BHE, and the majority of pediatric BHEs attended by EMS result in transport of the child. Use of sedation medications and physical restraints by prehospital clinicians in these events is rare. National EMS data from a variety of sources should continue to be examined to monitor trends in EMS encounters for BHEs in children.

Characteristics of pediatric behavioral health emergencies in the prehospital setting.

Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

Investigating Racial Disparities in Chemical and Physical Restraint of Mental Health Patients in the Emergency Department.

The primary aim of this study is to examine whether racial disparities exist in the use of physical or chemical restraints in the emergency department (ED). The secondary aim is to explore if there are disparities in type or intensity of restraint. We examined ED encounters for acute mental health crises from a single health system over a 3-year period. Univariate and multivariate logistic regression models were used to examine associations of race/ethnicity with primary outcomes of physical and/or chemical restraint and a measure of restraint intensity among patients physically restrained. The study sample included 18,938 ED encounters with completed psychiatric consultations representing 13,316 unique patients. Restraint use was experienced by one-third of the sample (32.6%): 27.9% chemical restraint, 0.8% physical restraint, 3.9% both physical and chemical. In adjusted logistic regression models, odds of chemical restraint were lower for non-Hispanic (NH) Black (OR 0.83, 95% CI: 0.74, 0.93), NH Asian (OR 0.63, 95% CI: 0.47, 0.83), and Hispanic (OR 0.79, 95% CI: 0.65, 0.95) patients relative to NH White, with no difference for NH American Indian and multiracial. In the models assessing physical restraint use, there were no statistically significant differences by race/ethnicity. Among patients who were physically restrained, there were no differences in the adjusted models of high versus low intensity of the restraint type used. Among ED patients at high risk for restraint, patients of minority race/ethnicity were not found to have increased likelihood of restraint or intensity of restraint.