Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments

Abstract

OBJECTIVES: Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described. METHODS: This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3–21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint. RESULTS: Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18–21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59–2.22), male sex (OR, 1.25; 95% CI, 1.16–1.34), Black race (OR, 1.22; 95% CI, 1.09–1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45–1.96), or the weekend (OR, 1.26; 95% CI, 1.22–1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17–1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, –0.15 to –0.04) with no significant association between average annual ED volume and restraint (95% CI, –0.25 to 0.25). CONCLUSIONS: For children in the ED with MBH conditions, ages 18–21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.

De-escalation Techniques for the Agitated Pediatric Patient

“…39,40 In addition, racial and ethnic disparities in both pediatric physical and pharmacologic restraint use have been shown. 41,42 Although the adverse effects of restraint use have been well described in the literature, and there is insufficient evidence to support restraint use as a safe or effective intervention, restraints may be necessary at times to prevent injury to patients and providers. [43][44][45] The use of restraints should be avoided whenever possible.…”

“…Restraints can cause psychological distress and retraumatization, increase risk of serious injury to patients and staff, and have even resulted in death 39,40 . In addition, racial and ethnic disparities in both pediatric physical and pharmacologic restraint use have been shown 41,42 . Although the adverse effects of restraint use have been well described in the literature, and there is insufficient evidence to support restraint use as a safe or effective intervention, restraints may be necessary at times to prevent injury to patients and providers 43–45 .…”

Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments

“…18 While the algorithm includes 30 groups, in line with prior analyses, we restricted the analysis to nine that have been demonstrated to be associated with mental health emergencies: hyperactivity, anxiety, bipolar, disruptive, neurocognitive, substance, trauma, depressive, suicide/self-injury (Supplemental Table S1). 1,11 For each patient, we recorded age, sex, race and ethnicity, insurance, mental health diagnosis, and disposition. Consistent with prior literature, we dichotomized age into children (8-12 years old) and adolescents (13-17 years old).…”

“…In these studies, 3.5%-6.8% of pediatric patients with a behavioral health emergency received an IV/IM chemical restraint. 1,[9][10][11] Several studies among adult and pediatric patients with behavioral emergencies have found associations between physical restraints and race and ethnicity. Specifically, some studies have found that Black males are at higher risk of being treated with both chemical and physical restraints; however, this has not been consistently demonstrated across studies.…”

“…1,[12][13][14] Importantly, prior studies among pediatric populations have been limited to freestanding children's hospitals yet the majority of pediatric ED visits (80%) occur in community hospitals. 11,15 It is unknown whether IV/IM chemical restraint use related to behavioral emergencies differs in general EDs or those with minimal pediatric subspecialty support. As a result, we sought to describe IV/IM chemical restraint use and associations with patient and hospital factors among children presenting with mental health conditions across a large consortium of U.S. hospitals.…”