A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children with Mental and Behavioral Health Conditions in the Emergency Department

Abstract

Background:

Mental health visits to the emergency department (ED) by children are rising in the U.S., and acute agitation during these visits presents safety risks to patients and staff.

Objective:

We sought to assess barriers and strategies for providing high quality care to children who experience acute agitation in the ED.

Study Design:

We conducted semi-structured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about experiences with acute agitation care in the ED, barriers and facilitators to providing high quality care, and proposed interventions. Interviews were coded and analyzed thematically.

Results:

Participants discussed identifying risk factors for acute agitation; worrying about safety and the risk of injury; feeling moral distress; and shifting the culture towards patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities.

Conclusion:

Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.

INTRODUCTION

Mental health emergency department (ED) visits by children and adolescents have more than doubled from 2009 to 2019.(1) During these visits, some children experience acute agitation, which is excessive psychomotor activity or aggressive behavior that may culminate in violence, resulting in injuries to patients or staff.(2) Consensus guidelines from the American Association for Emergency Psychiatry recommend managing pediatric acute agitation with verbal de-escalation before considering medications,(2) while physical restraint should be reserved for cases with imminent safety risks.(3) Acute agitation is common, with as many as 12% of children seen in the ED for a mental health condition receiving intramuscular medication for acute agitation management and 5-10% receiving physical restraint.(1,4) As children are increasingly boarded in EDs for prolonged durations while awaiting psychiatric placement,(5,6) greater attention is needed to improve care for this population.

Children who experience acute agitation in the ED deserve to receive high quality care that is safe, effective, patient-centered, timely, efficient, and equitable.(7) While quality measures were recently developed to assess quality of care for pediatric acute agitation management,(8) few interventions have been developed or tested to improve care along these measures. The design of such interventions must be grounded in an in-depth understanding of barriers and facilitators to providing high quality care. While prior qualitative work has elicited perspectives of ED staff related to providing mental health care for children,(9) the inquiry did not focus specifically on acute agitation care, and perspectives of parents and children were not included.

The goals of this investigation were (1) to describe parent, patient, physician, and nurse experiences related to pediatric acute agitation in the ED, (2) to identify barriers and facilitators to providing high quality care for acute agitation, and (3) to identify proposed interventions to improve acute agitation care for children with mental health conditions.

METHODS

Study Design and Setting

We conducted semi-structured interviews of parents, adolescents, physicians, and nurses from August to November 2021 at an academic, urban children’s hospital with 56,000 annual ED visits and a 12-bed inpatient psychiatric unit. The ED serves a diverse population with patients identifying as American Indian/Alaska Native (0.1%); Asian (5.4%); Black/African American (10.9%); Native Hawaiian/Pacific Islander (0.1%); other/unknown races (34.2%); and White (49.3%). Ethnicities represented are Hispanic/Latinx (27.3%); Non-Hispanic/Latinx (61.4%); and other/unknown ethnicities (11.3%).

In the ED, acute agitation is managed by pediatric emergency medicine physicians and emergency department nurses utilizing the Welle Behavioral Safety Management method.(10) In 2020, a care pathway was implemented to standardize initial management of pediatric acute agitation, including verbal de-escalation and medication administration (11). Psychiatric social workers are available for consultation 24 hours-per-day to assist with determining the level of psychiatric care that children need, but they do not assist with management of acute agitation. Based on internal quality improvement data, 98% of episodes of moderate to severe acute agitation requiring medication in our ED occur among patients with mental or behavioral health diagnoses.

The multidisciplinary research team consisted of three pediatric emergency medicine physicians [JAH, AAF, AK], a child and adolescent psychiatrist [AP], a medical student who previously worked as an ED nurse [JW], and an expert in quality improvement and qualitative methods [JKJ]. The study was approved by the hospital’s institutional review board and adhered to COREQ guidelines.(12)

Selection of Participants

We used purposive sampling to recruit 6 ED physicians, 6 ED nurses, 6 parents of children who had developed agitation in the ED or who had a mental health condition that could predispose them to develop acute agitation in a medical setting, and 6 adolescents 12-17 years old who had developed agitation in the ED or who had a mental health condition that could predispose them to develop acute agitation in a medical setting. Participants were required to have the ability to complete an interview in English. Adolescents were ineligible to participate if they had significant cognitive impairment or were in the custody of social services. Parents of children with significant cognitive impairment were eligible to participate.

Physicians and nurses were recruited via email invitation. Parents and adolescents were recruited in the ED or after the ED visit by telephone. Of 38 parents and adolescents invited to participate, 2 were ineligible, 3 declined to participate, 13 missed their scheduled interview, and 12 participated in the study. Interviews were conducted until theoretical sufficiency was reached.

Interview Guide Development

The study lead (JAH) developed separate interview guides for each participant type (Table S1), which were revised through discussion among the research team. Interview guides were reviewed by the hospital’s family education services team to enhance readability and developmental appropriateness.

Adult participants were provided with the following definition of acute agitation: “behaviors such as yelling, pacing, head banging, throwing objects, swinging at staff, or biting,” (13) while adolescents were asked about episodes of “getting upset or acting out” in the ED, with this wording chosen to align with their developmental stage. Interviews opened by asking participants about past experiences related to acute agitation in the ED. To understand context and barriers to care, subsequent questions were structured using a theoretical domains framework (e.g., knowledge, skills, beliefs, environmental context, emotions).(14) Additional questions on barriers to care, along with questions eliciting proposed interventions, were structured to address six domains of healthcare quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.(7) Participants self-reported demographics and years of experience working in the ED.

Data Collection

Research team members (JAH, AK, AP) conducted interviews over teleconference or in person, lasting 60 minutes for physicians, nurses, and parents, and 30 minutes for adolescents. Only the researcher and participant were present during interviews. Interviews were digitally recorded, transcribed, and reviewed for accuracy.

Analysis

We used a combination of inductive and deductive coding to develop initial codes and a codebook, followed by reflexive thematic analysis to identify higher order themes.(15-19) Transcripts were entered into qualitative data analysis software (MAXQDA 2022, VERBI Software, Berlin, Germany). Utilizing established methods from prior qualitative studies of ED and inpatient pediatric mental health care (9)(13), at least two members of the study team independently coded each transcript. Study team members met at regular intervals to discuss and revise emerging codes until a codebook was finalized (Table S2). These codes were then independently applied to each transcript by two study team members [JAH and either AK, AP, AAF, or JW]. Coding discrepancies were resolved through discussion. We used constant comparison to consider variation in perspectives across roles (physicians, nurses, parents, adolescents).

RESULTS

Characteristics of interviewees are presented in Table 1. Themes were grouped into three categories: (1) experiences of pediatric agitation care, (2) barriers and facilitators to providing high quality care, and (3) proposed interventions.

Table 1.

Participant Characteristics

Participant Characteristic	N (%)
Participant Role
Emergency Department Physician	6 (25)
Emergency Department Nurse	6 (25)
Parent of Child at Risk of Agitationa	6 (25)
Adolescent at Risk of Agitationb	6 (25)
Gender Identity
Female	16 (67)
Male	5 (21)
Nonbinary	3 (12)
Race and Ethnicity
Non-Hispanic White	16 (67)
Non-Hispanic Black	3 (13)
Hispanic	3 (13)
Non-Hispanic Asian	1 (4)
Declined to report	1 (4)
Child’s Psychiatric History c
Attention-Deficit/Hyperactivity Disorder	3 (50)
Depression	3 (50)
Generalized Anxiety Disorder	2 (33)
Oppositional Defiant Disorder	2 (33)
Autism Spectrum Disorder	1 (17)
Intermittent Explosive Disorder	1 (17)
Selective Mutism	1 (17)
Sensory Processing Disorder	1 (17)
Significant Cognitive Impairment	1 (17)
Healthcare Staff Years of Experience Working in the Emergency Department,d median [IQR]	16.5 [9.75, 29]

^a.Parents or guardians of children who developed agitation in the ED, or who had a behavioral or mental health condition that could predispose them to develop agitation in a medical setting.

^b.Adolescents who had developed agitation in the ED, or who had a behavioral or mental health condition that could predispose them to develop agitation in a medical setting. Adolescents ranged in age from 12 to 17, with a median age of 14.

^c.Child’s psychiatric history, as described by participating parents. Percentages add to over 100% as some children had multiple diagnoses.

^d.Only physicians and nurses were asked about years of experience.

Experiences of Pediatric Acute Agitation Care in the Emergency Department

We identified four themes related to experiences of pediatric acute agitation care in the ED: identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture towards patient-centered, trauma-informed care (Table 2).

Table 2.

Experiences and Characteristics of Acute Agitation Care

Theme	Exemplar Physician and Nurse Quotes	Exemplar Parent and Adolescent Quotes
Identifying risk factors for acute agitation	“I think the kids with certain associated developmental disorders including autism seem to have a greater propensity or risk potential for agitation in part because it’s difficult to deploy some of the standard techniques.” (Physician)	“People asking her the same thing over and over, she gets agitated when she’s in pain… The wait time most definitely took a number one major role in it.’ (Parent) “Sometimes it can be as simple as being overtired or being hungry, but other times it seems to be random.” (Parent)
Worrying about safety and the risk of injury	“Some of these kids are 16, 17-years-old and larger than me. And if you’re literally stuck in this room by yourself and things go south that’s a really not great scenario.” (Physician) “Multiple times as we’re restraining… the patient lifts their head up and takes a big bite out of somebody.” (Physician)	“It makes it very difficult to both protect yourself, protect your child, and protect your things from incurring damages at the hands of your child.” (Parent)
Feeling moral distress	“Emergency department nurses like to fix things and make them better… It’s not like a popsicle is going to make this better.” (Nurse) “When you have four people on every limb of an eleven-year-old, it’s disturbing. There’s got to be another way.” (Nurse) “I think that we fail these patients, sadly.” (Nurse)	“The security puts me in the quiet room, and then when I calm down, let me out… Annoying. I hate them… I don’t know if they should pin down kids because that’s just brutal.” (Adolescent)
Shifting the culture towards patient-centered, trauma-informed care	“I’m old enough to [remember when] it was much more punitive, right?… It wasn’t a patient-centered approach… We also were not kind. It’s sad to say. It’s not something you want to look back on and I’m happy to see things have changed.” (Physician) “These behaviors are born out of being scared and it’s a trauma response, they don’t trust anyone and I think… most of these kids have really, really good reasons for that.” (Nurse)	“I specifically wanted a pediatric hospital. I love that this is so child-focused and child-centered.” (Parent)

Identifying Risk Factors for Acute Agitation

Physicians and nurses perceived that children at high risk for developing acute agitation were those with substance use, autism spectrum disorder, and neurodevelopmental disorders. For example, one nurse described how children with autism spectrum disorder face challenges navigating transitions that can prompt agitation: “there is just so much change… that it’s just a tea kettle that finally whistles.” Healthcare staff found that de-escalation strategies were more difficult to employ among non-verbal children.

Triggers for agitation reported by parents and adolescents included physical needs (e.g., hunger, pain, sleep deprivation), unfamiliar people, fear of security staff, repetitive questioning by medical staff, and long wait times. Some described agitation occurring randomly, with one parent remarking, “you know, not every child has those easily identifiable triggers.”

Worrying about Safety and the Risk of Injury

Physicians and nurses worried about the risk of injury during episodes of acute agitation. One nurse admitted, “When the child is much bigger and much stronger than I am, it’s really hard not to be a little bit afraid.” Some parents also expressed fear of injury during episodes of acute agitation, while other parents were concerned about injury to their child from self-harm behaviors such as biting and head banging.

Feeling Moral Distress

Physicians and nurses experienced moral distress because they felt obligated to help their patients, yet they felt unable to adequately address their patient’s mental health needs due to system constraints. Many described repetitive cycles of care. For instance, a nurse lamented, “I feel very, very frustrated and sad because for so many of these patients, we medicate them to de-escalate them, they de-escalate for a period of time, then we watch them re-escalate… and it’s just this never-ending cycle.” Nurses observed that children at risk for agitation returned frequently to the ED.

Healthcare staff found the application of physical restraint to be particularly unsettling and distressing. Similarly, adolescents described feeling distress when they received intramuscular medication and restraints. One described his experience: “I’m having a complete meltdown and someone comes and stabs me in the leg with a needle and I have no idea what’s going on. Is it like the child consents to it?”

Shifting the Culture Towards Patient-Centered, Trauma-Informed Care

Physicians and nurses perceived a decrease in stigma related to mental illness over time, with care becoming more patient-centered. One physician described, “Twenty years ago it really wasn’t about families, it was about us, right? It was unfortunately very pejorative care and that has gone away.” Staff endorsed taking a non-judgmental, trauma-informed approach that acknowledges life circumstances that preceded the episode of acute agitation. One nurse reflected, “No one is born and just decides to be a challenging patient... They have had so many things happen to them. They’ve had so many people let them down.”

Barriers and Facilitators to Pediatric Acute Agitation Care

We identified four themes regarding barriers and facilitators to pediatric acute agitation care: using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members (Table 3).

Table 3.

Barriers and Facilitators to Pediatric Acute Agitation Care

Theme	Exemplar Physician and Nurse Quotes	Exemplar Parent and Adolescent Quotes
Using a standardized care pathway	“There’s a very clear pathway of first line, second line medications that I think really helps control the situation much faster.” (Nurse) “Sometimes I use the workflow to push the point to physicians… this is what we should be doing.” (Nurse)	“It’s like trying to put out a small fire before it turns a huge one.” (Parent)
Identifying environmental barriers and allocating resources	“It is not unusual when a patient has hit the severe agitation point that it requires four to seven humans and that’s a combination of nursing, physicians, residents, security.” (Physician) “If you have a couple other really sick kids it’s hard to be as available as you want to be for agitated patients.” (Nurse)	“We tried to dim the lights, make it less stimulating, make it more calming for him but we can only do so much when he doesn’t like his environment.” (Parent) “Based on something they saw on their computer or whatnot, it made them decide my issue wasn’t important as the other issues. It was 50 minutes less important… Even if it’s an issue that’s less severe doesn’t mean it’s not still bothering that person.” (Adolescent)
Partnering with the family and child	“The family and the patient are part of this decision making… Giving them as much control in management as possible back to them is important.” (Nurse) “Manage expectations, see what immediate needs there are, answer questions. All of that front end work is gonna pay off because then you’re gonna have this cool, calm, cooperative kid that for the rest of the night is gonna be chill, ya know?” (Nurse)	“If the child is not calm and is crying, they probably wouldn’t want to talk, so they should ask the parents if they need anything… I know the parent knows what the child needs.” (Adolescent) “They treated me with respect. Like they care about you and they want you to feel better and they want to do everything they can.” (Adolescent)
Communicating among team members	“I feel like it is pivotal and really important that the bedside nurse is involved and is listened to, because that person probably has been… involved in that child’s care prior to that and should be part of the decision-making process.” (Nurse) “Most everything is just done through the EMR [electronic medical record], which is sad that we’ve lost the ability to communicate with each other, but it’s something that’s happened with computers.” (Nurse)	“There’s nothing like dealing with an already agitated child and then having different providers ask the same set of questions over and over again.” (Parent)

Using a Standardized Care Pathway

Physicians and nurses described benefits of using a standardized care pathway for acute agitation management. The pathway ensured a stepwise approach from least to most invasive strategies and expedited care. One physician described, “the dosing is right there, the meds are right there. You don’t have to try to figure it out.” Moreover, nurses felt the pathway facilitated communication among team members.

Identifying Environmental Barriers and Allocating Resources

Physicians, nurses, and parents found that the loud, stimulating ED environment made de-escalation challenging. Responses to acute agitation required multiple staff members – sometimes as many as typically needed for critical care resuscitations. Due to the time-consuming nature of verbal de-escalation, both physicians and nurses perceived that inadequate staffing contributed to increased medication and restraint use. One physician quipped, “it’s sort of easy to give the medicine but harder to talk somebody down.” Nurses felt torn between allocating time to preventing acute agitation and caring for other patients.

Healthcare staff reported that patients at risk for acute agitation often remained in the ED for many hours, due to difficulty finding community mental health resources or inpatient psychiatric beds. The length of visits was perceived to increase risk for re-escalation. In tandem, parents and children felt ignored due to long waits. One parent explained, “We were just waiting and waiting… it made me feel like we weren’t very important.”

Partnering with the Family and Child

Physicians and nurses saw parents as valuable care partners, particularly in sharing patient-specific triggers and de-escalation strategies. Parents appreciated when staff respected their opinions, engaged in shared decision-making, and recognized that parents knew their children best. Both nurses and parents felt that investing time establishing rapport with children reduces risk of subsequent agitation. Important steps included setting expectations, answering questions, active listening, and treating patients with compassion and humanity.

Adolescents appreciated small gestures of kindness from the medical team. One adolescent noted, “My doctor… was really determined to get me my snacks. I thought that was really kind.” Adolescents trusted and confided in their medical teams, with one describing, “If you’re ever feeling any emotion, just tell your nurse or tell your doctors because they can help you.” They desired clear explanations about next steps, with developmentally appropriate communication. One adolescent described how he didn’t want to be treated “like I’m an adult,” while another disliked how “they always talk to me like I’m a 5-year-old.”

Communicating among Team Members

During episodes of acute agitation, nurses appreciated when team leaders communicated a shared mental model and clearly designated team roles. Nurses often felt dismissed by physicians when they tried to raise concerns about escalating agitation, with one nurse remarking, “It’s usually the nurses most of the time that are begging the physicians to order something for the patient.”

Parents reported frustration when multiple care team members asked similar clinical questions, as they perceived staff were not communicating with each other. Parents desired inclusion of their child’s longitudinal care providers, such as therapists and outpatient psychiatrists, in decision-making when possible.

Proposed Interventions to Improve Acute Agitation Care

Participants proposed nine interventions to improve pediatric acute agitation care in the emergency department (Table 4). We will discuss each in turn.

Table 4.

Proposed Interventions to Improve Pediatric Acute Agitation Care

Theme	Exemplar Quote
Opening a behavioral observation unit with dedicated staff and space	“If you had a specialized area that was unique to caring for that patient population, then you could hire people with that skill and communication set.” (Nurse)
Asking screening questions in triage to identify risk of agitation	“What are some of the things the kids like, what helps their agitation? You already have it documented and you’ll be ready.” (Parent)
Creating personalized care plans in the electronic health record	“I think what would be nice for some of these kids who are repeat visitors is to have somewhere in their chart an emergency agitation plan.” (Physician) “For those who are like my son, it would be very helpful if the emergency room doctors would have at least an idea of who he is instead of just coming in the room.” (Parent)
Using a standardized agitation severity score	“This numerical scale, it kind of reminds me of acuity.” (Nurse)
Implementing a behavioral response team	“Bringing in expertise to the fray maybe a little sooner than later is probably a good idea. That’s one of the things a rapid response team might achieve.” (Physician)
Providing safe activities and environmental modifications	“Having some more kiddo-friendly, sensory-friendly distractions available would be great.” (Parent) “When I got in, it kind of calmed me down because… I really liked the design on the walls” (Adolescent).
Improving the handoff process	“I think things have gotten missed when a nurse went home at 11, 1, 2, 3, and then 7… what strategies worked, what have we tried.” (Nurse) “I always appreciate an introduction from one nurse to the next… [reviewing] medications and any pertinent diagnoses as well as what we’ve tried so far that did not work… That gives everybody a chance to be on the same page.” (Parent)
Educating staff	“Education. I just want education. I want the tools to take care of these patients. I have the tools to take care of every other patient. I think they deserve the respect and honor of people knowing how to take care of them in their most difficult times.” (Nurse) “A behavioral health nurse who is trained in de-escalation techniques… [would be my] number one draft pick.” (Parent)
Addressing bias and inequities	“If we start treating psychiatric patients as actual patients like we treat the kids with cancer, asthma, epilepsy, acute appendicitis, I think that we will give them better care… When we start to think of them like they belong in the emergency department, in their acute moment of distress we can equitably take care of them.” (Nurse)

Opening a Behavioral Observation Unit with Dedicated Staff and Space

Physicians and nurses suggested that having dedicated, well-trained staff with ample time to conduct verbal de-escalation could reduce the use of medications and restraint. Staff desired dedicated space for patients with mental and behavioral health conditions, such as a behavioral observation unit staffed by experienced nurses.

Asking Screening Questions to Identify Risk of Agitation

Physicians, nurses, and parents suggested asking questions during triage to assess the patient’s risk of developing agitation. One parent proposed questions such as, “Does your child have a history of agitation, are you worried that they may become agitated today, [and] do they have any specific needs?” Nurses desired integration of questions into electronic health record workflows, with positive responses triggering prevention strategies, such as discussion of patient-specific triggers and consultation of child life services.

Creating Personalized Care Plans in the Electronic Health Record

For children with a history of acute agitation, physicians, nurses, and parents recognized the value of personalized care plans embedded in the electronic health record. They postulated that such plans should include patient-specific triggers, de-escalation strategies, and recommended medications for the child. Physicians and nurses desired easily accessible care plans that highlight only the most relevant information. A nurse explained, “I’m not going to spend 20 minutes trying to find this in the chart and reading a three-page exposé on what works for this child.”

Using a Standardized Agitation Severity Scale

Nurses noted inconsistent wording used to describe agitation severity levels, resulting in communication barriers across the care team. They suggested that a numeric agitation severity scale would standardize communication, and might also reduce bias by increasing objectivity of assessments.

Implementing a Behavioral Response Team

Physicians and nurses agreed that team coordination could be improved by implementing a behavioral response team, defined as a structured, standardized response to bring personnel immediately to the bedside to address episodes of acute agitation. Participants agreed that the team should include security staff and personnel trained in de-escalation techniques.

Providing Safe Activities and Environmental Modifications

Nurses and parents found activities helpful to distract patients during long wait times, but parents reported that these activities were underutilized. Adolescents agreed that participating in activities such as deep breathing exercises and drawing helped them remain calm. Some adolescents felt frustrated that ED staff did not allow them to use their phones to connect with friends. Friendly environmental decorations made adolescents feel at ease and reduced their anxiety.

Improving the Handoff Process

Nurses and parents both identified handoffs as vulnerable times for information loss. One nurse proposed creating a specific note type to document episodes of acute agitation and successful de-escalation strategies. One parent proposed that parents be included in the nursing handoff process, while another suggested using a visual communication board in the patient’s room to convey information during handoffs.

Educating Staff

Physicians and nurses believed they could benefit from additional education on acute agitation management. Suggested modalities included interdisciplinary simulation, brief videos demonstrating de-escalation techniques, and feedback following real cases. Requested educational content included identifying agitation severity, verbal de-escalation techniques, and working with children with autism spectrum disorder. Parents and adolescents perceived that ED staff lacked sufficient training related to mental health care and de-escalation.

Addressing Bias and Inequities

Physicians and nurses recognized the need to address bias and inequities in the care of children with mental health conditions. For instance, one physician suggested that EDs review their own data to identify differences in use of medications for acute agitation and physical restraints by race and ethnicity. She reflected, “only by knowing our flaws can we try to revise behavior.” One parent suggested that increased diversity among hospital staff would improve care, as she commented that “seeing Black doctors, seeing Asian doctors, seeing doctors of different walks of life helps.”

DISCUSSION

This qualitative study allowed for a multifaceted understanding of the experience of caring for children with acute agitation in the ED. Physicians, nurses, parents, and patients identified barriers and facilitators to providing high quality care for acute agitation management, and they proposed nine interventions to improve care.

Participants identified that children with autism spectrum disorder and neurodevelopmental disorders were at high risk for developing acute agitation. A prior single-center study determined that more than 1 in 10 inpatient medical admissions by children with autism spectrum disorder involve episodes of acute agitation, with higher risk conferred by a history of severe agitation and sensory sensitivities.(20) In a study of mental health ED visits across 32 U.S. children’s hospitals, intramuscular medications were administered for acute agitation during 15.8% of visits by children with neurodevelopmental disabilities, compared with 3.7% of all mental health ED visits.(1) As specific interventions to improve care for this population, participants in our study suggested dedicated staff education and embedding personalized care plans in the electronic health record.

Participants desired earlier identification of patients at risk for agitation, through the development of agitation risk screening questions. A 14-item scale, the Brief Rating of Aggression by Children and Adolescents (BRACHA), accurately predicts aggressive behavior in children during inpatient psychiatric hospitalization,(21,22) but its predictive validity among children in the ED has not been established. Another scale, the Brøset Violence Checklist, was used during a quality improvement initiative to reduce restraint use in the pediatric inpatient setting, (23) but its predictive validity among children remains unclear. Earlier identification of children at risk for agitation through such a tool could prompt preventive interventions.

ED physicians and nurses described moral distress when caring for children with acute agitation, particularly in the application of physical restraints. ED staff felt that they were ill-equipped to address underlying mental health conditions contributing to the child’s presentation, resulting in frequent return ED visits. In prior qualitative work focused on hospital staff perceptions of caring for children with mental health needs and agitation, moral distress was similarly identified as a predominant theme.(9,13) Fortunately, participants in our study perceived that care has become more patient-centered over time with increased use of trauma-informed approaches. At one inpatient psychiatric hospital, robust implementation of trauma-informed prevention strategies resulted in the elimination of restraint use,(24) but it remains unclear whether similar results are attainable in an ED environment.

Educational interventions desired by healthcare staff included simulation, brief educational videos on de-escalation, and feedback following real cases. Multidisciplinary simulation training has been demonstrated to improve staff confidence in managing acute agitation, with impacts enduring for months following training.(25) A self-paced online module on pediatric agitation care, including videos demonstrating de-escalation techniques, has been developed by the Emergency Medical Services for Children Innovation and Improvement Center.(26) Mentorship from more experienced staff was similarly identified as a desired learning strategy in prior qualitative work.(13) One mechanism to facilitate this learning is through a behavioral response team, which brings trained staff to the bedside for de-escalation. Behavioral response teams have been demonstrated to reduce security calls, restraint use, and staff injuries, while moderately improving staff knowledge and staff efficacy through structured debriefing after episodes of agitation.(27)

In many ways, the ED environment was perceived as a major barrier to care due to few available activities, long wait times, and competing staff priorities. One proposed intervention was to open a behavioral ED observation unit with dedicated staff and space. EmPATH (Emergency Psychiatric Assessment, Treatment, and Healing) units located adjacent to EDs are an emerging model to provide psychiatric observation care for adults. These units are designed with open spaces that allow for freedom of movement, with intensive treatment provided by a multidisciplinary team (28) Adults treated in EmPATH units experience lower admission rates, decreased return visits, and increased attendance at follow-up visits.(29) Such models are not widely available for children, but one study found that opening a behavioral observation unit at a children’s hospital significantly reduced ED length of stay.(30) Even without opening a designated unit, simple interventions such as providing safe activities may help children tolerate time spent in the ED.(13,31) In one exemplar model, activity kits for children experiencing mental health boarding were distributed to rural and low pediatric volume EDs throughout Vermont, with clinical staff reporting high utilization and acceptability.(32) In addition, more robust community and mobile crisis outreach services might allow more children and families to avoid visiting the ED altogether.(33)

Physicians and nurses found that having a standardized care pathway for agitation management facilitated communication among team members and expedited care. Such tools may be particularly helpful for emergency physicians and nurses with limited mental health training who may feel less comfortable using psychotropic medications.(34) In one pediatric ED, standardizing pharmacologic treatment via an agitation algorithm did not reduce restraint use,(35) whereas in another ED, a comprehensive agitation pathway did reduce time spent in restraints.(11) Additional work is needed to understand whether implementation of a standardized care pathway for agitation decreases medication use and reduces injuries to patients and staff. Future investigations should also determine whether standardized pathways improve equity in care delivery. Concerningly, Black children are more likely to receive both pharmacologic and physical restraints in the ED than White children,(36,37) with contributing factors including implicit bias and structural racism.(38) Standardization of care has effectively narrowed disparities for other pediatric emergency conditions.(39)(40)

Our study had several limitations. We did not capture the perspectives of parents or children with limited English proficiency, or of children in the custody of juvenile justice or social services. We conducted the study at an academic children’s hospital, and facilitators and barriers to agitation management at other hospital types may differ.(41) Our findings may be influenced by the perspectives and lived experiences of the research team; however, we included team members from multiple disciplines to provide balance to analytic discussions.

CONCLUSIONS

In summary, physicians, nurses, parents, and patients described their experiences, facilitators, and barriers to the care of children with acute agitation in the ED, including aspects of the environment and care processes. Integration of participant perspectives resulted in the identification of nine unique interventions to improve care. These findings provide the basis for future investigations of proposed interventions to improve care for children with acute agitation in the ED. Patient and family voices should continue to be centered as new interventions for acute agitation management are designed and evaluated.