Category: Mental Health

Categories
Mental Health

Agitation Episode 5: The boarded ED patient

We are in the midst of a staggering mental health crisis. Thousands of children and adolescents spend days at time in Emergency Departments waiting for definitive mental health disposition. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what we should consider when boarding children in the ED for mental health reasons. It is also the final episode in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify some of the reasons why we are boarding so many children in the ED and which children are the highest priority
  • Describe the challenges these patients face as they await inpatient psychiatric care
  • Describe best practices and what we should be doing for them 
  • Discuss some of the stresses that these children place on the healthcare system, and possible alternative strategies.

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 4: Safe prehospital transport of the agitated patient | Supplementary EMDocs.net article

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Fiona B. McEnany, Olutosin Ojugbele, Julie R. Doherty, Jennifer L. McLaren, JoAnna K. Leyenaar; Pediatric Mental Health Boarding. Pediatrics October 2020; 146 (4): e20201174. 10.1542/peds.2020-1174

AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health

Jennifer A. Hoffmann, Polina Krass, Jonathan Rodean, Naomi S. Bardach, Rachel Cafferty, Tumaini R. Coker, Gretchen J. Cutler, Matthew Hall, Rustin B. Morse, Katherine A. Nash, Kavita Parikh, Bonnie T. Zima; Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383

Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422. PMID: 31539324; PMCID: PMC6754202.

Cushing AM, Liberman DB, Pham PK, et al. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr. 2023;177(2):168–176. doi:10.1001/jamapediatrics.2022.4885

Nash  KA, Zima  BT, Rothenberg  C,  et al.  Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015).   Pediatrics. 2021;147(5):e2020030692. doi:10.1542/peds.2020-030692

Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children’s Mental Health Emergency Department Visits: 2007-2016. Pediatrics. 2020 Jun;145(6):e20191536. doi: 10.1542/peds.2019-1536. Epub 2020 May 11. PMID: 32393605.

Parent/Professional Advocacy League: Best Practices: Pediatric Emergency Department Psychiatric Boarding

Kraft CM, Morea P, Teresi B, et al. Characteristics, Clinical Care, and Disposition Barriers for Mental Health Patients Boarding in the Emergency Department. American Journal of Emergency Medicine. Nov. 2020. Doi.org/10.1016/j.ajem.2020.11.021

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Podcast: Play in new window | Download (Duration: 13:57 — 19.2MB)

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Categories
Mental Health

Agitation Episode 4: Safe prehospital transport

There are protocols in place that assist highly trained Emergency Medical Service providers in assuring that agitated children are safely transported to their destination. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what pre-hospital providers should do to get these agitated children safely to the ED. It is also episode 4 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify unique aspects of the pre-hospital environment that impact assessment and treatment of agitated children
  • Describe the role of EMS personnel and EMS director in the care of agitated children.
  • Describe the role of medical control in determining destination and goals of safe transport

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Kupas D et al. NASEMSO: Clinical care and restraint of agitated or combative patients by emergency medical service practitioners. https://nasemso.org/wp-content/uploads/Clinical-Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-Services-Practitioners.pdf

Patient restraint in emergency medical services [Position Statement]. Prehosp Emerg Care. 2017;21(3):395-396.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Podcast: Play in new window | Download (Duration: 15:51 — 21.8MB)

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Categories
Mental Health

Agitation Episode 3: Pharmacologic management

When we think of managing agitated patients we think of medicines – but that shouldn’t be our first option. However, medications can be adjuncts to non-pharmacologic means to help keep agitated children safe from harm. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about age-appropriate pharmacologic management strategies for agitated children. It is also episode 3 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Discuss the medications commonly used to treat acute agitation in children and adolescents
  • Discuss the different routes of administration to safely administer these medicines

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 4: Safe pre-hospital transport of the agitated child | Supplementary EM Docs Article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.

Foster AA, Saidinejad M, Duffy S, Hoffmann JA, Goodman R, Monuteaux MC, Li J. Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators. Acad Pediatr. 2023 Mar 21:S1876-2859(23)00091-8. doi: 10.1016/j.acap.2023.03.005. Epub ahead of print. PMID: 36948291.

Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open. 2022 May 11;12(5):e059876. doi: 10.1136/bmjopen-2021-059876. PMID: 35545394; PMCID: PMC9096567.

New A, Tucci VT, Rios J. A Modern-Day Fight Club? The Stabilization and Management of Acutely Agitated Patients in the Emergency Department. Psychiatr Clin North Am. 2017 Sep;40(3):397-410. doi: 10.1016/j.psc.2017.05.002. PMID: 28800797.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Podcast: Play in new window | Download (Duration: 19:53 — 27.3MB)

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Categories
Mental Health

Agitation Episode 2: Non-pharmacologic management

Agitated children should always be treated with dignity and respect. This entails utilizing the least invasive non-pharmacologic means of assisting them, before moving to physical or chemical restraints. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about age-appropriate non pharmacologic management strategies for agitated children. It is also episode 2 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Discuss specific age-appropriate non pharmacologic management strategies for agitated children
  • Discuss how we can safely use holds and restraints, and how these are temporary measures

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child | Supplementary EM Docs Article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012 Jan;109(3):27-32. PMC3272587.

Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.

Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.

Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. PMC3298214.

Melamed E, Oron Y, Ben-Avraham R, Blumenfeld A, Lin G. The combative multitrauma patient: a protocol for prehospital management. Eur J Emerg Med. 2007 Oct;14(5):265-8. PMID: 17823561.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Podcast: Play in new window | Download (Duration: 17:49 — 24.5MB)

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Categories
Mental Health

Agitation Episode 1: Differentiating organic versus psychiatric

Most children who present to Pediatric Emergency Departments these days with mental health concerns – including agitation – have a known psychiatric problem or diagnosis. Furthermore, the connection between physical and functional symptoms is inextricably linked in many patients. Why then do we persist with the “is it medical/organic or psych” question? Ultimately, this episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is less about “is it psych or not” and more about not missing something because you assumed the patient had a mental or behavioral problem. It is also episode 1 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Describe the findings on history and physical examination that differentiate organic vs psychiatric causes of agitation and altered mental status.
  • Develop a strategy to differentiate organic from psychiatric causes of altered mental status, including using ancillary studies

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 2: Non-pharmacologic management of agitated children (Coming May 24, 2023)

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Hua LL, COMMITTEE ON ADOLESCENCE. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics 2021; 147.

Sedel F, Baumann N, Turpin JC, et al. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. J Inherit Metab Dis 2007; 30:631.

Chun TH, Sargent J, Hodas GR. Psychiatric emergencies. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. P.1820.

Cunqueiro A, Durango A, Fein DM, et al. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol 2019; 49:240.

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Podcast: Play in new window | Download (Duration: 22:31 — 30.9MB)

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