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. Author manuscript; available in PMC: 2025 Feb 1.
Published in final edited form as: Acad Emerg Med. 2023 Nov 27;31(2):129–139. doi: 10.1111/acem.14833

Characteristics of Pediatric Behavioral Health Emergencies in the Prehospital Setting

Julia H Wnorowska 1, Vishal Naik 2, Sriram Ramgopal 2, Kenshata Watkins 3, Jennifer A Hoffmann 2
PMCID: PMC10922610  NIHMSID: NIHMS1945951  PMID: 37947152

Abstract

Objective:

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.

Methods:

We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019–2020 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.

Results:

Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% were 12–17 years old, 57.3% were female, and 86.6% 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% 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 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).

Conclusions:

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.

Keywords: Behavioral health, mental health, prehospital care, pediatrics, physical restraint

About ten percent of emergency medical services (EMS) dispatches in the United States are related to mental and behavioral health disorders.1 Of those, approximately 7% are for children, amounting to over 110,000 EMS encounters in 2018.2 About 1 in 5 children with behavioral health emergencies arrive to the emergency department (ED) by EMS,3 and ED visits by children for behavioral health care are continuing to increase over time.4,5

Pediatric prehospital behavioral health transports require distinct considerations, including weight-based medication dosing, attention to the child’s developmental level, and involvement of caretakers.6 Challenges specific to the prehospital environment include the confined space of the ambulance and limited available staff to assist in de-escalation.7 Patients can become acutely agitated during transport, requiring the use of verbal de-escalation, sedative medications, and/or physical restraints to mitigate risks of patient or staff injury.8–10 However, these interventions also carry their own risks. Adverse effects of sedative medications include dystonic reactions, respiratory depression, and arrythmias,11 while physical restraint use can lead to psychological harm and physical injuries.12

Despite the frequency of pediatric behavioral health EMS encounters and the risks involved in transport, a 2023 scoping review identified only four research publications regarding prehospital management of pediatric behavioral health emergencies.6 Three studies evaluated a specific sedative medication, droperidol.13–15 The fourth study, conducted in Florida from 2011–2016, found that 4% of pediatric prehospital behavioral health transports involved interventions such as sedative medication or physical restraint.16 Additionally, the systematic review found that only four U.S. states had protocols in place for prehospital management of pediatric behavioral health emergencies.6

Further characterization of pediatric behavioral health EMS encounters across the U.S. is needed to guide resource allocation, quality improvement, and protocol development, with the goal of reducing the use of restrictive interventions when safe to do so. Thus, our objective was to describe demographic, clinical, and EMS-system characteristics of pediatric behavioral health EMS encounters across the U.S., and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.

Methods

Study Design and Data Source

We performed a retrospective cross-sectional study of pediatric behavioral health EMS encounters utilizing a convenience sample of deidentified EMS encounters in the 2019–2020 National Emergency Medical Services Information System (NEMSIS) Version 3 of the Public Release Research Dataset.17 NEMSIS was founded in 2001 by the National Highway Traffic Safety Administration to standardize collection of EMS data and is managed by the Technical Assistance Center at the University of Utah. The dataset is deidentified and organized by individual EMS encounters rather than individual patients. The 2019 dataset included 34,203,087 EMS activations submitted by 10,062 EMS agencies in 47 states and territories, while the 2020 dataset included 43,488,767 EMS activations submitted by 12,319 EMS agencies in 50 states and territories.18 This study was reviewed and deemed non-human subjects research by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board.

Study Population

We included all EMS encounters for individuals <18 years of age with a primary or secondary impression of an International Classification of Disease, 10th Revision diagnosis code in the Childhood and Adolescent Mental Health Disorders Classification System (CAMHD-CS).19 CAMHD-CS is a validated classification of child mental health disorders, with diagnosis code groupings aligned with the Diagnostic and Statistical Manual of Mental Disorders.20

We excluded encounters with missing age or primary impression; encounters that involved interfacility transport (hospital-to-hospital), medical transport (i.e., dialysis, doctor appointment, return home, or hospital-nursing home transport),21 air transport, or water transport; and encounters with no patient care provided (Figure 1). No patient care was defined as “assistance” (manpower or equipment provided to a member of the public, another agency, or the same agency where there is either no patient or the EMS unit is not responsible for primary patient care at any time during the incident), canceled, patient dead at scene with no resuscitation attempted, patient refused evaluation/care, standby, and non-patient transport such as organ transport.

Figure 1.

Figure 1.

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Encounter Inclusion/Exclusion Flow Diagram

EMS: Emergency Medical Services; CAMHD-CS: Childhood and Adolescent Mental Health Disorders Classification System.

Study Measures

The primary outcome variables were the use of sedative medications and physical restraint. We defined sedative medications as chlorpromazine, clonidine, diazepam, diphenhydramine, droperidol, haloperidol, ketamine, lorazepam, midazolam, olanzapine, quetiapine, risperidone, and ziprasidone. These medications have been described in the literature as treatment for acute agitation in children in the prehospital or ED setting10,11,22 and/or are listed within state EMS protocols for pediatric behavioral health encounters (from Maryland, Utah, Rhode Island, and Michigan).6

We examined demographic, clinical, and EMS-related characteristics, which were chosen based on prior literature suggesting relevance to behavioral health EMS encounters.2,13 We examined the following demographic characteristics: age (0–5, 6–11, and 12–17), sex (male, female), urbanicity (urban, suburban, rural, wilderness), race (American Indian or Alaska Native, Asian, Black or African American, Hawaiian or Other Pacific Islander, Hispanic or Latino, and White), and U.S. Census region (Northeast, South, West, Midwest).23 Patient demographics (age, sex, and race) are documented in NEMSIS by the recording EMS clinician.

As clinical characteristics, we assessed the primary impression; alcohol or drug use; and the presence of a developmental, communication, or physical disability. Primary impressions were classified using CAMHD-CS mental health diagnosis groups (anxiety disorders; disruptive, impulse control, and conduct disorders; substance-related and addictive disorders; suicide or self-injury), “other mental health,” and non-mental health primary impression.20 The “other mental health” category included the CAMHD-CS categories of Miscellaneous and Mental Health Symptom, as well as CAMHD-CS categories representing less than 1.5% of the study sample (e.g., depressive disorders, schizophrenia spectrum and other psychotic disorders, trauma and stressor-related disorders). Non-mental health primary impressions were further categorized using the NEMSIS Primary Impression Suggested List (Supplemental Table 1).17 A binary variable for alcohol or drug use was considered positive if any of the following variables were positive: alcohol containers/paraphernalia at scene, drug paraphernalia at scene, patient admits to alcohol use, patient admits to drug use, positive level known from law enforcement or hospital record, or smell of alcohol on breath. A developmental, communication, or physical disability was defined using the “barriers to care” variable as a physical, hearing, speech, sight, or developmental impairment.

We assessed the following EMS system characteristics: EMS system organization type (fire department, governmental non-fire, hospital, private - nonhospital, tribal), EMS system organization status (non-volunteer, volunteer, mixed), level of practice of EMS personnel (Basic Life Support [BLS], Advanced Life Support [ALS], critical care), location found, scene time interval, and transport time interval. BLS personnel were defined as emergency medical technicians (EMTs), first responders, emergency medical responders, and EMT-Intermediate personnel. ALS personnel were defined as advanced EMTs, paramedics, and community paramedics. Critical care personnel included physicians, nurses, physician’s assistants, and other critical care personnel. Location was categorized as private residence, public area (defined as commercial, public area, recreational, street, other), school, health care facility, and institutional residence.

Analysis

We calculated descriptive statistics for demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters. We performed univariate and multivariable logistic regression models to determine demographic, clinical, and EMS system characteristics associated with (1) sedative medication administration, (2) physical restraint use, and (3) either sedative medication administration or physical restraint use. Characteristics were chosen for inclusion in the models a priori due to clinical experience and/or prior literature suggesting relevance.24–26 Because race was missing for 58% of encounters in the study sample, race was not included in the models. We excluded EMS encounters that had missing data for one or more variables of interest from the models. Collinearity diagnostics were performed for each model; no variance inflation factor exceeded 2. As a sensitivity analysis, we performed similar models among the subset of encounters with a mental health primary impression. Analyses were performed using R, version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria) and STATA 16.0 (Stata Corp, College Station, TX).

Results

We identified 2,740,271 pediatric EMS encounters, of which 309,442 (11.3%) were behavioral health EMS encounters. Among pediatric behavioral health EMS encounters, 57.3% were by females, 85.2% were 12–17 years old, and 86.6% occurred in urban areas (Table 1). Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively; 4.6% of encounters involved either intervention. The 6,790 encounters with sedative medication administered included 4,221 (62.1%) encounters with midazolam, 1,068 (15.7%) with ketamine, 837 (12.3%) with haloperidol, 847 (12.5%) with lorazepam, 641 (9.4%) with diphenhydramine, 88 (1.3%) with diazepam, 41 (0.6%) with ziprasidone, 40 (0.6%) with olanzapine, and 32 (0.5%) with droperidol administered. Clonidine, chlorpromazine, quetiapine, and risperidone were not administered during any pediatric behavioral health EMS encounters. The West Census region accounted for 26.6% of pediatric behavioral EMS encounters and 55.5% of all physical restraint use. Scene time intervals for EMS encounters with sedative medication or restraint use lasted a mean of 19.1 minutes, compared with 13.2 minutes for all pediatric behavioral health EMS encounters (Table 2).

Table 1.

Sociodemographic and Clinical Characteristics of Pediatric Behavioral Health EMS Encounters

All Included Encounters Encounters with Sedative Medication Use Encounters with Restraint Use Encounters with Either Sedative Medication or Restraint Use
N = 309,442 N = 6,790 N=9,414 N=14,252
2.2% 3.0% 4.6%
Age (years), N (%)
 0–5 7,448 (2.4) 105 (1.6) 75 (0.8) 162 (1.1)
 6–11 38,324 (12.4) 681 (10.0) 1,488 (15.8) 1,927 (13.5)
 12–17 263,670 (85.2) 6,004 (88.4) 7,851 (83.4) 12,163 (85.3)
Sex, N (%)
 Male 130,542 (41.2) 3,228 (47.5) 5,214 (55.4) 7,367 (51.7)
 Female 177,328 (57.3) 3,542 (52.2) 4,185 (44.5) 6,853 (48.1)
 Missing 1,572 (0.5) 20 (0.3) 15 (0.2) 32 (0.2)
Race, N(%)
 American Indian or Alaska Native 1,231 (0.4) 25 (0.4) 36 (0.4) 52 (0.4)
 Asian 1,745 (0.6) 33 (0.5) 45 (0.5) 71 (0.5)
 Black or African American 33,174 (10.7) 720 (10.6) 1,063 (11.3) 1,558 (10.9)
 Hawaiian or Other Pacific Islander 309 (0.1) 10 (0.2) 11 (0.1) 18 (0.1)
 Hispanic or Latino 11,815 (3.8) 254 (3.7) 346 (3.7) 531 (3.7)
 White 82,013 (26.5) 1,907 (28.1) 2,561 (27.2) 3,923 (27.5)
 Missing 179,155 (57.9) 3,841 (56.6) 5,352 (56.9) 8,099 (56.8)
Urbanicity, N (%)
 Urban 267,833 (86.6) 5,886 (86.7) 8,743 (92.9) 12,853 (90.2)
 Suburban 14,334 (4.6) 305 (4.5) 212 (2.3) 456 (3.2)
 Rural 14,864 (4.8) 367 (5.4) 250 (2.7) 553 (3.9)
 Wilderness 3,313 (1.1) 62 (0.9) 29 (0.3) 84 (0.6)
 Missing 9,098 (2.6) 170 (2.5) 180 (1.9) 306 (2.2)
Census Region, N (%)
 Midwest 63,306 (20.5) 1,288 (19.0) 1,845 (19.6) 2,818 (19.8)
 Northeast 52,638 (17.0) 583 (9.0) 675 (7.2) 1,144 (8.0)
 South 111,000 (35.9) 2,840 (41.8) 1,670 (17.7) 3,846 (27.0)
 West 82,417 (26.6) 2,079 (30.6) 5,224 (55.5) 6,444 (45.2)
Primary Impression, N (%)
 Anxiety Disorders 46,297 (15.0) 748 (11.0) 163 (1.7) 878 (6.2)
 Disruptive, Impulse Control, and Conduct Disorders 9,560 (3.1) 144 (2.1) 124 (1.3) 243 (1.7)
 Substance-Related and Addictive Disorders 5,299 (1.7) 163 (2.4) 224 (2.4) 319 (2.2)
 Suicide or Self-Injury 31,638 (10.2) 314 (4.6) 445 (4.7) 661 (4.6)
 Other Mental Health1 180,126 (58.2) 4,034 (59.4) 7,278 (77.3) 9,933 (69.7)
 Non-Mental Health 36,522 (11.8) 1,387 (20.4) 1,180 (12.5) 2,218 (15.6)
Alcohol or Drug Use, N (%)
 Yes 25,209 (8.2) 1,060 (15.6) 1,353 (14.4) 1,984 (13.9)
 No 284,233 (91.9) 5,730 (84.4) 8,061 (85.6) 12,268 (86.1)
Developmental, Communication, or Physical Disability, N (%)
 Yes 2,860 (1.0) 226 (3.3) 216 (2.4) 396 (2.8)
 No 284,408 (99.0) 6,564 (96.7) 8770 (97.6) 13,856 (97.2)
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EMS: emergency medical services.

1

Other Mental Health included Miscellaneous, Mental Health Symptom, and mental health diagnosis categories representing less than 1.5% of the study sample. These diagnoses are listed in Supplemental Table 1.

Table 2.

EMS System Characteristics of Pediatric Behavioral Health EMS Encounters

All Included Encounters Encounters with Sedative Medication Use Encounters with Restraint Use Encounters with Either Sedative Medication or Restraint Use
N = 309,442 N = 6,790 N=9,414 N=14,252
2.2% 3.0% 4.6%
EMS System Organization Type, N (%)
 Fire Department 111,308 (36.0) 1,949 (28.7) 1,606 (17.1) 3,156 (22.1)
 Governmental Non-Fire 70,786 (22.9) 1,952 (28.8) 1,534 (16.3) 3,000 (21.1)
 Hospital 25,988 (8.4) 894 (13.2) 929 (9.9) 1,471 (10.3)
 Private – Nonhospital 100,522 (32.5) 1,985 (29.2) 5,338 (56.7) 6,609 (46.4)
 Tribal 838 (0.3) 10 (0.2) 7 (0.1) 16 (0.1)
EMS System Organization Status, N (%)
 Non-Volunteer 247,441 (80.0) 5,555 (81.8) 8,449 (89.8) 12,314 (86.4)
 Volunteer 6,879 (2.2) 50 (0.7) 58 (0.6) 100 (0.7)
 Mixed 55,122 (17.8) 1,185 (17.5) 907 (9.6) 1,838 (12.9)
Level of Practice by EMS Personnel, N (%)
 BLS 51,412 (16.6) 74 (1.1) 1,220 (13.0) 1,278 (9.0)
 ALS 253,050 (81.8) 6,590 (97.1) 7,942 (84.4) 12,627 (88.6)
 Critical Care 4,980 (1.6) 126 (1.9) 252 (2.7) 347 (2.4)
Location Found, (N, %)
 Private Residence 186,391 (60.2) 3,833 (56.5) 5201 (55.25) 7,921 (55.6)
 Public Area 51621 (16.7) 1,445 (21.3) 2052 (21.8) 3,010 (21.1)
 School 42,525 (13.7) 931 (13.7) 1258 (13.36) 1,984 (13.9)
 Health Care Facility 9,417 (3.0) 187 (2.8) 298 (3.17) 439 (3.1)
 Institutional Residence 7,439 (2.4) 202 (3.0) 363 (3.86) 500 (3.5)
 Missing 12,049 (3.9) 192 (2.8) 242 (2.57) 398 (2.8)
Time Intervals (min)
 Scene Time Interval, median (IQR) 13.2 (9.0, 19.6) 22.1 (16.0, 30.0) 18.1 (12.8, 25.7) 19.1 (13.6, 26.8)
 Transport Time Interval, median (IQR) 13.5 (8.2, 20.7) 14.0 (9.0, 21.0) 15.0 (10.0, 22.0) 14.5 (9.5, 21.6)
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EMS: emergency medical services; BLS: basic life support; ALS: advanced life support, IQR: interquartile range

Of pediatric EMS encounters, 7.2% had missing data for one or more variables and were excluded from models. Univariate model results are presented in Supplemental Table 2. In multivariable models (Figure 2, Figure 3, Supplemental Figure 1), there were lower adjusted odds of sedative medication use among EMS encounters by children 0–5 years old (adjusted odds ratio [aOR] 0.58, 95% CI 0.47, 0.71) and 6–11 years old (aOR 0.81, 95% CI 0.75, 0.89) relative to 12–17 years old. Sedative medication use was associated with the West Census region relative to the South (aOR 1.23, 95% CI, 1.16, 1.32) and the presence of developmental, communication or physical disabilities relative to their absence (aOR 3.38, 95% CI, 2.93, 3.91). There were higher adjusted odds of sedative medication use among ALS-trained (aOR 18.00, 95% CI 14.14, 22.92) and critical care clinicians (aOR 16.01, 95% CI 11.80, 21.71).

Figure 2.

Figure 2.

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Factors Associated with Sedative Medication Among Pediatric Behavioral Health EMS Encounters, Multivariable Logistic Regression

EMS: Emergency Medical Services; BLS: Basic Life Support; ALS: Advanced Life Support

Figure 3.

Figure 3.

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Factors Associated with Restraint Use Among Pediatric Behavioral Health EMS Encounters, Multivariable Logistic Regression

EMS: Emergency Medical Services; BLS: Basic Life Support; ALS: Advanced Life Support

Physical restraint use was associated with an age of 6–11 years old relative to 12–17 years old (aOR 1.35, 95% CI, 1.27, 1.44), males relative to females (aOR 1.56, 95% CI, 1.49, 1.63), the West Census region relative to the South (aOR 3.49, 95% CI, 3.27, 3.72), and the Midwest Census region relative to the South (aOR 2.18, 95% CI, 2.03, 2.34). The adjusted odds of physical restraint use was higher for primary impressions of disruptive, impulse control, and conduct disorders (aOR 1.46, 95% CI 1.19, 1.81) and substance-related and addictive disorders (95% CI 1.68, 95% CI 1.41, 2.00) compared with primary impressions related to suicide or self-injury. Additionally, physical restraint use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (aOR 2.23, 95% CI, 1.93, 2.59), with private, nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI, 3.18, 3.61), and with a location found at institutional residences (aOR 1.79, 95% CI, 1.59, 2.00) and public areas (aOR 1.53, 95% CI, 1.45, 1.62) relative to private residences.

In the sensitivity analysis of encounters with a mental health primary impression (Supplemental Table 3), factors that were significant remained consistent.

Discussion

In this retrospective cross-sectional study, we found that more than 1 in 10 EMS encounters for children were for behavioral health. Among pediatric behavioral health EMS encounters, we found that use of sedative medications and physical restraints varied significantly by patient and EMS-system characteristics, including region. While this variation could reflect differences in documentation or data quality, opportunities may also be available to standardize care practices such as the use of restrictive interventions. Standardization in care across regions could be accomplished through initiatives such as EMS clinician education and increased adoption of pediatric-specific protocols.

Our study adds to prior literature on pediatric behavioral health EMS encounters by characterizing the frequency of sedative medication and physical restraint use in the prehospital setting. In the ED, the use of medications to manage acute agitation in children occurs during as many as 3.5% of mental health-related visits and has increased over time.27,28 In the prehospital setting, we found a slightly lower frequency of sedative medication use, during 2.2% of pediatric behavioral health EMS encounters. We found that restraints were used in 3.0% of pediatric behavioral health EMS encounters, which is lower than the rate of 5.8% of all behavioral health EMS encounters (inclusive of children and adults) from 2018 NEMSIS data.2 Restraint use has previously been described in 15.3% of pediatric behavioral health EMS encounters in Alameda County, California,29 1.1% of pediatric behavioral EMS encounters in Florida,16 and 9% of pediatric behavioral EMS encounters in the Australian state of Victoria.30 Pediatric restraint rates in the prehospital setting appear comparable to rates described among pediatric behavioral health patients in the ED (ranging from 2.4% to 6.5%),31,32 despite limited staff in the prehospital setting who can engage in verbal de-escalation, and the lack of a secure environment such as a safe room.7,33

We identified variation in physical restraint use by demographic characteristics. We found that males were more likely to be restrained, which was similar to prior studies on restraint use in the prehospital setting among adults,2 in inpatient pediatric units,34 and in EDs among children.24,25 In contrast, prior studies in inpatient psychiatric and medical units did not find differences in restraint use by sex,35–37 which could be due to differences in the patient population, physical environment, or staff training. In the ED, adolescents are more likely to be physically restrained than younger children,24,31 while a meta-analysis of restraint use among inpatient mental health units found that younger children were more likely to be restrained.34 In the prehospital setting, we found increased odds of restraint use among patients 6–11 years old. A lack of comfort by prehospital clinicians in weight-based dosing of sedative medications might contribute to increased utilization of physical restraints in younger children.38 Additionally, few EMS agencies and states have pediatric-specific sedative medication protocols,6 leaving EMS clinicians with limited alternatives to restraint use until they are able to receive physician guidance or arrive to the ED.

We were unable to perform an analysis of disparities in care by race due to a high percentage of missing data for the race variable. Given that Black children have an increased odds of pharmacological and physical restraint compared to White children in the ED setting,32,39 it is important for future research to identify whether similar disparities exist in the prehospital setting. A necessary first step will be to improve the quality of data collection for race and ethnicity, including reducing the degree of missing data.

We also found that physical restraint use among children in the prehospital setting varied by clinical characteristics. Unsurprisingly, we found that restraint use was higher during EMS encounters for conduct disorders and substance use, compared with encounters for suicidality, which is often associated with depression or psychomotor slowing. Most importantly, however, we found that children with developmental, communication, and physical disabilities had three times higher odds of being restrained than children without these disabilities. Our results are consistent with a study of pediatric behavioral health EMS encounters in Australia, which found that children with a history of autism spectrum disorder had 2.5 times higher adjusted odds of parental sedative medication use.30 Children with autism spectrum disorder are more likely to visit the ED for a psychiatric condition than their peers,40 highlighting a need to educate prehospital clinicians on working with children with neurodevelopmental disabilities, including autism spectrum disorder.41 Also, specific interventions could be developed to prevent and reduce agitation in this population, such as personalized emergency information forms that delineate patient-specific triggers and de-escalation techniques.42

We found that the use of sedative medications and restraints varied across EMS system characteristics. Understandably, sedative medication use was much more likely when care was provided by clinicians trained in ALS relative to BLS, given that BLS-trained clinicians have a scope of practice which prohibits administration of sedative medications.43 However, in some cases, BLS-trained clinicians may have documented sedative medication administered by ALS-trained clinicians, if both types of clinicians responded to the scene. In contrast, we found that physical restraint use did not differ between ALS and BLS levels of practice. We identified higher odds of sedative medication use in the West Census region relative to the South, and higher odds of physical restraint use in the West and Midwest relative to the South. Additionally, restraints were used more often in private, nonhospital EMS systems relative to fire departments. As the NEMSIS database included only EMS transports, future work should also aim to understand rates of restraint use by law enforcement officers transporting children with behavioral health emergencies.

Further work is needed to understand why the use of these interventions varies by region and EMS system. These findings may be due to differences in training, variation in protocols, transport time and distance, or the culture of practice. Indeed, a 2015 study identified significant regional differences in the prevalence of statewide ALS protocols, which were least common in the West Census region (54%) and highest in the Northeast (78%).44 Variation in data quality and documentation practices may also contribute to differences across EMS systems and regions.45 For instance, a mixed methods study conducted in Michigan found that rates of missing and invalid data varied by agency and medical control area.46

Reduction of physical restraint use during prehospital encounters is a worthy goal. While there is limited literature on how children perceive the experience of being placed in physical restraints, some have hypothesized that restraint use may provoke a trauma response and induce future fears of medical care.47 In a qualitative study of restrained pediatric patients, participants described feeling like they were “being jumped,” experienced a sense of unpredictability, felt entrapped, and described the experience as traumatizing.48 Additionally, the use of physical restraints has been associated with physical injuries to both patients and staff.12,49 These risks must be balanced against the risk of injury to patients and to the EMS clinicians delivering care.

Opportunities are available to improve care delivered during pediatric behavioral health EMS encounters at both the individual encounter and system levels. At the individual encounter level, EMS clinicians can strive to meet the unique needs of children during behavioral health emergencies. EMS clinicians should be well-versed in verbal de-escalation techniques and may consider adjusting their approach based on the child’s cognitive abilities, communication skills, and the input of caretakers present at the scene.50 Since children often mirror the emotional states of their caretakers, EMS clinicians should strive to support caretakers during emergencies as well.50

Prior system-level improvement work has largely focused on behavioral health emergencies within the ED setting,51,52 but there are many opportunities to translate these efforts to the prehospital setting.53 Pediatric-specific protocols for management of behavioral health emergencies can be implemented in additional EMS agencies and states.6 Additionally, protocols can be designed to provide specific guidance for the care of children with neurodevelopmental disabilities. An expanded evidence base is needed to guide protocol development, including studies that evaluate which medications are most effective and safe for acute agitation management in children.54 In the hospital setting, multifaceted interventions have successfully decreased restraint use in children. These strategies have included multidisciplinary education, simulation training, standardized protocols, and structured debriefing after events.42,55–58 Adaptation of these strategies to the prehospital setting may be considered, along with strategies unique to the prehospital setting, such as specialized behavioral crisis response teams that include mental health professionals trained in de-escalation.59 Future work is needed to develop and test interventions to reduce the use of sedative medications and restraints in children in the prehospital setting, while also maintaining patient and staff safety.

Limitations

While NEMSIS provides a large sample of EMS encounters in the U.S., it relies on convenience sampling and is not a nationally representative sample, which can result in selection bias. Individual patient identifiers are not available in NEMSIS, limiting our analyses to the encounter level. There is potential for reporting bias, as we are unable to determine if missing data differed systematically from reported data. We were unable to assess for racial disparities in care due to the percentage of missing data for the race variable.

While the validity of many NEMSIS variables has improved over time,45 the validity of behavioral-health specific variables remains uncertain; absence of documentation may not equate to absence of interventions such as medication administration or restraint use. Further, documentation of information was performed by EMS clinicians and some misclassification may have occurred, such as in primary impression codes. Because some infrequent mental health diagnoses were categorized together as “other mental health” primary impression in our analysis, our understanding of practice patterns for these mental health diagnoses remains limited. There may also be underreporting or inconsistent documentation of the “barriers to care” variable, such as the presence of developmental disabilities, particularly when the condition did not considerably affect the transport.

Conclusion

We found that more than 1 in 10 EMS encounters for children are for behavioral health. Among pediatric behavioral health EMS encounters, the use of sedative medications and physical restraint varies by patient and EMS-system characteristics. While regional variation in sedative medication and restraint use could reflect differences in documentation or data quality, this variation may also reflect varying practice patterns that may benefit from standardization. Future work should determine whether the use of restrictive interventions can be reduced, while simultaneously promoting staff safety, through strategies such as education and adoption of pediatric-specific protocols.

Supplementary Material

Supplemental Figure 1

Supplemental Figure 1. Factors Associated with Either Sedative Medication or Restraint Use Among Pediatric Behavioral Health EMS Encounters, Multivariable Logistic Regression

EMS: Emergency Medical Services; BLS: Basic Life Support; ALS: Advanced Life Support

Supplemental Table 1
Supplemental Table 2
Supplemental Table 3

Funding Sources:

Supported by the U.S. Agency for Healthcare Research and Quality (5K12HS026385-03 to JAH). The funders had no role in the design and conduct of the study.

Footnotes

Disclosure Statement: The authors report there are no competing interests to declare.

Prior Presentations: National Association of EMS Physicians 2023 Annual Meeting, January 23-28, 2023, Tampa, FL.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Figure 1

Supplemental Figure 1. Factors Associated with Either Sedative Medication or Restraint Use Among Pediatric Behavioral Health EMS Encounters, Multivariable Logistic Regression

EMS: Emergency Medical Services; BLS: Basic Life Support; ALS: Advanced Life Support

NIHMS1945951-supplement-Supplemental_Figure_1.pdf (243.5KB, pdf)
Supplemental Table 1
NIHMS1945951-supplement-Supplemental_Table_1.docx (16.2KB, docx)
Supplemental Table 2
NIHMS1945951-supplement-Supplemental_Table_2.docx (22.4KB, docx)
Supplemental Table 3
NIHMS1945951-supplement-Supplemental_Table_3.docx (23.5KB, docx)

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