Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department

Abstract

Background and objectives: Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints.

Methods: A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints.

Results: During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71.

Conclusions: Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.

FIGURE 1

Key driver diagram indicating key drivers and interventions to improve pediatric acute agitation care.

FIGURE 2

Individual and moving range (XmR) chart: Minutes in physical restraint per restraint episode, August 2014 to February 2022. Each point in the top panel represents the duration of physical restraint use in minutes for a single episode of physical restraint use. The centerline was calculated using data from August 2014 to August 2020 to establish an estimate of baseline minutes in restraint per episode before the intervention period. The lower panel displays the moving range.

FIGURE 3

Run chart: Intramuscular medication used first, September 2017 to February 2022, by quarter. Numerator: Intramuscular (as opposed to oral) route for the first medication administered for acute agitation during the ED visit. Denominator: ED visits with medication given for acute agitation.

FIGURE 4

Run chart: Olanzapine or droperidol chosen for severe agitation, September 2017 to February 2022, by quarter. Numerator: Administration of olanzapine or droperidol. Denominator: ED visits with medication given for severe agitation, defined by:

1. IM administration of diphenhydramine, lorazepam, olanzapine, haloperidol, chlorpromazine, or droperidol; or

2. oral administration of olanzapine and a psychiatric chief complaint for the ED visit.