Children and adolescents with severe acute behavioural disturbance in the emergency department

Abstract

Objective: Mental health (MH) presentations to ED are increasing in children and adolescents. Little is known about patients with severe acute behavioural disturbance (ABD). We set out to describe patients with ABD severe enough to trigger an acute crisis team response in ED (termed 'Code Grey') and how they differ from other MH patients. Methods: Retrospective electronic medical record review of all ED patients with MH discharge codes at a tertiary children's hospital. We assessed the epidemiology and management of patients who triggered acute crisis team interventions (Code Grey) as proxy for severe ABD. We calculated the odds ratios (ORs with 95% confidence intervals) of key demographic factors compared to other MH patients. Results: During 2018, there were 85 347 ED presentations of which 1695 (2.0%) were related to MH diagnoses; 84 MH patients had 141 MH presentations triggering 204 Code Greys (26 patients triggered 59% of Code Greys). These patients had higher triage acuity (OR 12.6 [8.3-19.0]), stayed longer in ED (>12 h OR 8.2 [5.1-13.1]) and were more likely to be admitted (OR 2.0 [1.4-3.0]) compared with non-Code Grey MH presentations. Patients were physically (19.2%), mechanically (31.9%) or chemically restrained (37.6%). Eight different medication approaches were used as either a single agent or a combination of oral and/or intramuscular agents. Conclusions: Children and adolescents with severe ABD differ from other MH presentations and often require physical or chemical restraint. Anticipatory management plans may be valuable for repeat presenters.

Factors associated with paediatric and adolescent Emergency Department presentations involving acute behavioural disturbance events

“…A previous study by Grover explored an innovative model of care involving a combined paediatric ED/mental health behavioural unit leading to a significant reduction in security time required 20 . Such innovations would require an early intervention approach as our data, like that of Carison, suggest that greater than 70% of ABD episodes occur within 2 h of arrival in ED 6 …”

“…14 Use of physical restraint or therapeutic sedation was required in 34.6% presentations in our study with 27.3% having restraint only and 23.5% receiving sedation only. Carison et al report a greater use of both physical restraint and sedation at 51% and 37.6%, respectively, 6 with a significantly higher proportion of sedation administered via the oral route. Our inclusion of prehospital sedation data, exclusively by the IM route, was a notable difference between the two studies.…”

“…Our median LOS was 5.1 h for those discharged but increased to just under 4 days in those admitted. Whilst not directly comparable due to differing methodology, the Carison data report an ABD event as being associated with a longer LOS 6 …”

“…This study concluded ABD events to be associated with a disproportionate use of physical restraint and pharmacological sedation when compared with other mental health presentations not requiring code grey activation. 6 Whilst this study only included those with a mental health diagnosis code, this comprised almost 70% of all code greys suggesting mental health complaints to be a significant precipitating factor. 6 A wider exploration of related literature in this age group indicates an increasing frequency of presentations to ED with mental health and other related complaints such as deliberate self-harm and deliberate self-poisoning.…”

“…This study concluded ABD events to be associated with a disproportionate use of physical restraint and pharmacological sedation when compared with other mental health presentations not requiring code grey activation. 6 Whilst this study only included those with a mental health diagnosis code, this comprised almost 70% of all code greys suggesting mental health complaints to be a significant precipitating factor. 6 …”