Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions

Abstract

Objective:

We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported.

Methods:

This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends.

Results:

Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001).

Conclusions:

Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.

While children and adolescents with acute mental and behavioral health (MBH) concerns had previously accounted for only 2% to 3% of pediatric emergency department (ED) visits,^1,2 these numbers have been dramatically increasing over the last decade.^3–6 Regarding the prehospital environment, there has been an increase in the proportion of all emergency medical service (EMS) calls for psychiatric concerns⁷ and higher numbers of adult psychiatric and drug-related calls for law enforcement.⁸ A growing body of prehospital research demonstrates that MBH calls impose a mounting burden on prehospital systems, as patients with acute MBH concerns are more likely to arrive at the ED via EMS than patients with non-MBH concerns,^1,9 and these patients tend to be repeated users of prehospital systems.¹⁰ In addition, MBH patients who need acute interventions by EMS require more time and resources in the prehospital setting than those not needing acute interventions.¹¹ Unique to children and adolescents, seasonal spikes in ED visits for MBH concerns during school semesters, compared to summer, suggest the potential for similar trends in EMS and police transports during academic semesters.^12–14

The intersection of law enforcement with pediatric MBH patients is poorly understood but of urgent importance. Historically, MBH encounters have made up about 1% of police calls, but transportation by police is increasing for adult patients with MBH diagnoses, representing up to 43% of police transports to the hospital in 1 study.⁸ While some studies have investigated the demographic factors associated with EMS utilization for pediatric patients with MBH concerns,^9,11,15 there is a lack of research describing the characteristics of pediatric patients transported by police.¹⁶ The adoption of various MBH crisis intervention models, both inclusive and exclusive of police presence, may offer potential benefits in promoting safe transportation. However, consistent evidence is lacking, particularly for children, and implementation heavily relies on available resources, leading to significant variation in practice across the United States.¹⁷ A better understanding of the frequency and characteristics of police transports for children and adolescents is crucial as it may mirror the concerning trend observed in adults and significantly impact the overall experience and outcomes for pediatric patients with MBH crises.

To identify unique characteristics and outcomes of pediatric MBH patients transported to the ED by EMS and police, we aimed to assess the epidemiology and temporal trends in the transport of these patients and to compare the demographics, ED interventions, and ED outcomes for those transported to the ED by EMS or police to those who self-transported. We hypothesized that the proportion of pediatric MBH patients arriving by EMS or police would increase over the duration of the study with the peak of transports for MBH patients expected during school academic semesters. We further hypothesized that pediatric MBH patients transported by EMS or police would be more resource intensive as measured by having a higher admission rate and requiring more acute psychiatric interventions in the ED, including pharmacologic, physical, or mechanical restraints. We conducted additional data analysis to identify the independent factors predicting the use of restraints in the ED. Gaining insight into the unique characteristics of pediatric MBH patients transported by EMS and police will facilitate the design of targeted age-appropriate strategies to ensure safe prehospital management and transport to appropriate destinations.

Methods

Study Design and Setting

This is a retrospective cohort study using hospital-based electronic health record data from patients ages 5 to 18 years evaluated for an acute MBH condition in 1 of 2 affiliated free-standing pediatric EDs from January 1, 2012 through December 31, 2020. These are the sole pediatric EDs serving a large metropolitan area of 5000 square miles with a population of over 2.2 million people. These EDs are uniquely equipped with dedicated and trained personnel specifically focused on pediatric mental health intake. The study was determined to be exempt by the local institutional review board.

Study Population

Acute MBH conditions were identified using a rubric of diagnostic codes and chief complaints developed by the institution for MBH quality improvement initiatives (complete logic available upon request). Patient encounters were included based on the following International Classification of Diseases, Tenth Revision (ICD-10) codes: F6–7, F10-F48, F50–51, F53–55, F59–60, F63–66, F68, F84-F94, F98–99, R45.850-R45.851, Z62.820, Z72.810, T36-T51, T54, T56–57, T65, Z72.89. The chief complaints and ICD-10 codes mapped to the following categories derived from the Diagnostic and Statistical Manual of Mental Disorders: mood, anxiety, stress-related, disruptive, psychotic, neurodevelopmental, or eating disorders, substance abuse, and intention to harm self or others. Additionally, patient encounters were included who required an MBH evaluation by mental health intake personnel and whose chief complaint was consistent with an MBH concern, including known psychiatric conditions or recorded as “psych evaluation,” “psychiatric evaluation,” “agitation–psych,” or “nonaccidental ingestion.” Only encounters with a mode of arrival documented were included, and patient encounters were categorized as self-transport (arrived via their own mode of transportation), EMS (arrived by local or regional ground ambulance or air transport), and police (brought in by a local or regional police officer). Encounters were excluded if they left without being seen, never arrived, or presented via interfacility transport.

Data extracted from the electronic health record included patient demographics (age, sex, race and ethnicity, language, and insurance type), visit date, ED psychiatric interventions, Brief Rating of Aggression by Children and Adolescents (BRACHA) score, diagnosis, and ED outcomes. Data for race and ethnicity were self-reported, categories for analysis include non-Hispanic Black (hereafter, Black), Hispanic or Latino (hereafter, Hispanic), and non-Hispanic White (hereafter, White), and other or unknown races or ethnicities are reported together. Seasonality was defined by months: fall (September–November), winter (December–February), spring (March–May), and summer (June–August). In the ED, acute psychiatric interventions captured were restraint use (mechanical, physical, or pharmacologic). Mechanical restraint was defined as the use of any device or material that restricts movement. Physical restraint was defined as the use of physical force to restrict movement. Pharmacologic restraint encompassed the administration of sublingual and intramuscular medications in line with our ED clinical care guidelines for agitation/aggression. These include Olanzapine, Risperidone, Ziprasidone, Aripiprazole, Chlorpromazine, Haloperidol, Lorazepam, and Midazolam.¹⁸ When completed by our MBH staff members, the BRACHA score was extracted. This 14-point scale assesses the risk of aggressive behavior, where a score of 4 or greater is associated with an increased risk of aggressive behavior in inpatient units.^19,20 Patient outcomes included ED disposition categorized as admission (including admissions to the inpatient psychiatric wards associated with our hospital, medical ward, and pediatric intensive care unit [PICU]), discharge from the ED, transfer to another facility, or other).

Data Analysis

The population was characterized using descriptive statistics with comparisons based on the mode of transport to the ED. These comparisons were made using chi-square analysis for categorical variables and the Wilcoxon rank sum test for continuous variables. A multivariable logistic regression model was derived to assess for predictors of restraint use in the ED (mechanical, physical, or pharmacologic). The primary variable of interest was mode of transportation to the ED, and covariates included age, sex, race, and ethnicity, insurance type, and language. Yearly trends were analyzed using linear regression. Seasonality was analyzed using a chi-square test. Missing data were not imputed, and the degree of missingness is noted in the tables. All statistical analysis was performed in IBM SPSS Statistics Version 26.0 (Armonk, NY) and SAS Version 9.4 (SAS Institute Inc., Cary, NC).

Results

Characteristics of Study Population

During the 9-year study period, there were a total of 440,302 encounters for patients 5 to 18 years old at the 2 affiliate EDs, of which 70,557 (16%) presented for an acute MBH condition meeting inclusion criteria. Of all MBH patient encounters, 56,104 (79.5%) were self-transported, 10,299 (14.6%) were transported by EMS, and 4154 (5.9%) were transported by police. Demographics of the patient population are described in Table 1. Patients transported by EMS and police were significantly older, about twice as likely to be Black, and more likely to have public insurance than those who self-transported (P < 0.001). Those transported by police were more likely to be male compared to patients who self-transported (P < 0.001). For all MBH patients, the most common diagnoses were mood disorders (25,900, 36.7%) and disruptive disorders (11,956, 16.9%). Twenty-eight percent of EMS transports and 41.4% of police transports were for patient encounters with mood disorders, and 18.8% of EMS transports and 25.6% of police transports were for patient encounters with disruptive disorders. Supplementary Appendix A provides additional details for all diagnoses for patient encounters included in this study.

Table 1.

Demographic Information for Patient Encounters for an Acute Mental or Behavioral Health Condition According to Mode of Transportation

	All Patient Encounters (n = 70,557)	Patient Encounters Who Self-Transported (n = 56,104)	Patient Encounters Transported by EMS (n = 10,299)	Self Versus EMS Transport	Patient Encounters Transported by Police (n = 4154)	Self Versus Police Transport
Age, years: median (IQR)	14 (5)	14 (4)	14 (4)	P < 0.001	14 (4)	P < 0.001
Male sex	33,284 (47.2)	26,213 (46.7)	4871 (47.3)	P = 0.283	2200 (53.0)	P < 0.001
Race and ethnicity				P < 0.001		P < 0.001
White	45,538 (64.5)	37,396 (66.7)	6326 (61.4)		1816 (43.7)
Black	17,872 (25.3)	13,079 (23.3)	2851 (27.7)		1942 (46.8)
Hispanic	2437 (3.5)	1954 (3.5)	366 (3.6)		117 (2.8)
Other/Unknown	4710 (6.7)	3675 (6.6)	756 (7.3)		279 (6.7)
English primary language*	69,733 (98.8)	55,483 (98.9)	10,145 (98.5)	P < 0.001	4105 (98.8)	P = 0.815
Public insurance†	40,281 (57.1)	30,659 (54.6)	6500 (63.1)	P < 0.001	3122 (75.2)	P < 0.001

EMS indicates emergency medical services; IQR, interquartile range.

All reported values are n (% of the column) unless otherwise indicated.

^*Language unknown for 12 patients (0.0%).

^†Insurance unknown for 26 patients (0.0%).

Temporal Trends

During the study period, total yearly ED visits decreased overall from 58,115 in 2012 to 35,654 in 2020 (Fig. 1, bar graph). This trend of decreasing ED volumes remained true from 2012 to 2019 even when eliminating 2020, during which national pediatric ED volumes decreased due to the coronavirus disease 2019 pandemic. However, despite the decrease in total ED visits, the proportion of visits for an MBH encounter increased during the study period from 9.9% to 19.8% (Fig. 1, line graph). The linear regression model showed that the proportion of MBH encounters compared to all ED encounters increased by 1.2% per year (95% confidence interval (CI) [0.7, 1.7], P = 0.0009). There were more MBH encounters in the ED during the fall, with the lowest number of encounters during the summer (P < 0.001) (Fig. 2). This seasonal variation was similar for self-transported patient encounters and those patient encounters transported by EMS or police.

Figure 1.

Breakdown of emergency department (ED) patient encounters per year. The volume of mental and behavioral health (MBH) patient encounters and all other encounters (bar graph, left axis). Percent of MBH patient encounters as a proportion of all ED encounters (line graph, right axis).

Figure 2.

Mental and behavioral health (MBH) patient encounter arrivals by month for each transportation type (self, emergency medical services [EMS], and police). Values for each month are the proportion of patient encounters for the specific transportation type during that month with all study years combined compared to the total MBH patient encounters for that transport type during the entire study period.

The proportion of encounters for MBH patients transported by EMS and/or police increased significantly from 17.6% in 2012 to 20.1% in 2020 (95% CI [0.08, 0.7], P = 0.02). The proportion of encounters for MBH patients transported by police remained relatively stable throughout the study period (95% CI [−0.2, 0.2], P = 0.96), but according to the linear regression model, the proportion of encounters for MBH patients transported by EMS increased significantly by 0.4% per year (95% CI [0.2, 0.6], P = 0.006) (Fig. 3).

Figure 3.

Proportion of emergency medical services (EMS) and police transports of mental and behavioral health (MBH) patient encounters over time (2012–2020) with a linear trend.

ED Interventions and Patient Outcomes

Overall, encounters by patients transported by EMS and police were significantly more likely to be administered pharmacologic, physical, or mechanical restraints in the ED compared with patients who self-transported (Table 2). For the 2757 encounters in which patients were administered pharmacologic restraints, 3506 medication doses were administered. The most common medications used for pharmacologic restraint were Olanzapine (2021, 57.6%) and Ziprasidone (1160, 33.1%). Of all encounters, 33,865 (48%) were admitted to the hospital, and 35,059 (49.7%) were discharged home from the ED. Other dispositions from the ED included discharge to a long-term care facility (23, 0.03%), outpatient clinic (84, 0.12%), and jail (377, 0.53%), transfer to another facility (884, 1.25%), discharge against medical advice (202, 0.29%), or elopement (61, 0.09%). Encounters for patients transported by EMS or police were more likely to require admission for ongoing management than those who self-transported (P < 0.001). Encounters for patients transported by EMS were also significantly more likely to require PICU admission than those who self-transported (P < 0.001); however, encounters for patients transported by police were significantly less likely to require PICU admission than those who self-transported (P < 0.001) (Table 2).

Table 2.

ED Interventions and Admissions for Encounters for Self-Transported Patients Compared to Encounters for Patients Transported by EMS and Police^*

	All Patient Encounters (n = 70,557)	Patient Encounters Who Self-Transported (n = 56,104)	Patient Encounters Transported by EMS (n = 10,299)	Patient Encounters Transported by Police (n = 4154)
Patient encounters who received pharmacologic restraint	2757 (3.9)	1721 (3.1)	734 (7.1)	302 (7.3)
Patient encounters who received mechanical restraint	1242 (1.8)	679 (1.2)	380 (3.7)	183 (4.4)
Patient encounters who received physical restraint	1942 (2.8)	1266 (2.3)	457 (4.4)	219 (5.3)
Admissions	33,865 (48.0)	26,112 (46.5)	5541 (53.8)	2212 (53.2)
PICU admissions	653 (0.9)	300 (0.5)	346 (3.4)	7 (0.2)

ED indicates emergency department; EMS, emergency medical services; and PICU, pediatric intensive care unit.

All reported values are n (% of the column).

^*All comparisons (self-transported vs emergency medical service and self-transported vs police) are statistically significant, P < 0.001.

Of the patient encounters included in this study, BRACHA was performed for 32,906 (46.6%), including for 27,976 (85.0%) of admitted patients. The BRACHA was completed for a significantly lower proportion of encounters transported by EMS (4415, 42.9%) and a higher proportion of encounters transported by police (2291, 55.2%) than for those who self-transported (26,200, 46.7%) (all comparisons significant with P < 0.001). Table 3 describes BRACHA scores for the patient population. In the subgroup analysis of patient encounters where the BRACHA was performed, median BRACHA scores were significantly higher for encounters for patients transported by EMS or police compared to those who self-transported (P < 0.001). The proportion of patient encounters with a BRACHA score of 4 or greater was also significantly higher for EMS or police transports compared to those who self-transported (P < 0.001). As was the case for the entire study population, for the subgroup of encounters for patients for whom the BRACHA was completed, patient encounters transported by EMS or police required significantly more ED interventions (pharmacologic, mechanical, and physical restraints) and had higher rates of admission than those who self-transported (P < 0.001 for all comparisons).

Table 3.

BRACHA Scores and Risk Stratification (BRACHA Score ≥4) for Encounters for Self-Transported Patients Compared to Encounters for Patients Transported by EMS and Police^*

	All Patient Encounters (n With BRACHA Completed = 32,906)	Patient Encounters Who Self-Transported (n With BRACHA Completed = 26,200)	Patient Encounters Transported by EMS (n With BRACHA Completed = 4415)	Patient Encounters Transported by Police (n With BRACHA Completed = 2291)
Median BRACHA score (IQR)	4.0 (1.5,7.0)	3.5 (1.0, 6.5)	5.5 (2.5, 8.0)	6.0 (3.5, 8.0)
BRACHA score ≥4 (n, %)	17,236 (52.4)	12,612 (48.1)	2913 (66.0)	1711 (74.7)

BRACHA indicates Brief Rating of Aggression by Children and Adolescents; EMS, emergency medical services; and IQR, interquartile range.

^*All comparisons (self-transported vs emergency medical service and self-transported vs police) are statistically significant, P < 0.001.

A total of 70,545 (99.98%) encounters had complete data for inclusion in the multivariable logistic regression model evaluating predictors of ED restraint use. Transportation to the ED by EMS or police was a significant predictor of the need for restraint in the ED. The odds of restraint use for patient encounters transported by EMS or police were over 2 times that of self-transported patient encounters (odds ratio for EMS, 2.26 [95% CI, 2.10–2.44]; odds ratio for police 2.33 [95% CI, 2.10–2.59]). Demographic covariates that were significantly associated with increased odds of restraint use were male patients (odds ratio 1.85 [95% CI, 1.74, 1.98]), non-White race (odds ratio for Black patients 1.42 [95% CI, 1.32, 1.52], odds ratio for other/unknown race 1.17 [95% CI, 1.05, 1.30]), and patients with public insurance (odds ratio 1.48 [95% CI, 1.37, 1.59]). Older patients had lower odds of restraint use (odds ratio 0.95 [95% CI, 0.94, 0.96]).

Discussion

In 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association²¹ joined together to declare a National State of Emergency in Children’s Mental Health. This study confirms the decade-long alarming trend of increasing MBH visits to pediatric EDs.^2,3,22 Despite a decrease in overall ED visits, pediatric MBH visits now comprise almost 20% of ED encounters in the hospital system studied. This trend was stable during the time period of the coronavirus disease 2019 pandemic included in this study, while others have described an increase in MBH visits during the pandemic.^23,24

Although the proportion of police transports for pediatric MBH patients has remained stable, there has been a steady and significant increase in the proportion of pediatric patients with MBH concerns transported to the ED by EMS. Previously described seasonal trends in more patients presenting in the fall for MBH emergencies¹² were confirmed in our population. Resources and advocacy efforts should be dedicated to supporting EMS to manage the increasing burden of caring for this patient population.

This large pediatric retrospective cohort demonstrates that pediatric patients with acute MBH concerns who are transported by EMS or police have an increased likelihood of aggressive behavior and require more ED interventions to deescalate acute agitation/aggression than patients who self-transport, including higher odds of pharmacologic, physical, and mechanical restraint use. As such, the subpopulation of pediatric MBH patients transported to the ED by EMS or police appears to have greater symptom severity. This underscores the essential need for the preparation and training of prehospital clinicians and police officers to effectively manage aggressive patient behaviors. Improved education, including the use of novel educational techniques such as simulation,²⁵ increased resources dedicated to this patient population, and collaboration between EMS and police will be crucial to ensuring clinician and patient safety during the care of pediatric patients with MBH emergencies.

Our study found that patients with acute MBH concerns transported by EMS and police were older, more likely Black, and publicly insured. We also found that transportation by EMS or police, male sex, non-White race, and public insurance were significant predictors of the use of restraints in the ED. In our study, the overrepresentation of Black and publicly insured patients in EMS and police transports may underscore disparities in mental health resource access or differential triage, leading to heightened reliance on EMS and police in crisis situations. Specifically, the significantly higher number of encounters for Black MBH patients transported by police in our study mirrors emerging data in the adult emergency literature.²⁶ The finding that these patients were then also more likely to be restrained in the ED demonstrates that there are also significant disparities in the care of patients with MBH emergencies in the ED. Our findings add to the growing literature about disparities among patients with MBH, which may be attributed to structural, institutional, and interpersonal racism.²⁷

The development of objective and streamlined ED and prehospital tools to assess the risk of aggressive behavior could help ED providers, EMS clinicians, and police safely and equitably assess and manage pediatric patients with MBH emergencies. Additionally, research on protocolized prehospital management of MBH emergencies is limited.²⁸ Although data are emerging on those patients who most commonly require pharmacologic restraint in the prehospital setting,^29,30 further research to ascertain a more nuanced understanding of the most common diagnoses for pediatric MBH patients utilizing EMS and police services will also be important to hone any interventions and to develop novel community resources, crisis response strategies, and field management protocols for pediatric patients with MBH emergencies.

Limitations

The large number of pediatric MBH patient encounters included in this study enhances its generalizability compared to smaller studies; however, its scope is somewhat limited as this study was only a single hospital system in 1 geographic region. Nevertheless, the comprehensive inclusion criteria and recognition of our hospital as the primary pediatric psychiatric evaluation center in the region reduce the likelihood of missing eligible patients. The retrospective nature of the study led to limitations in the data fields collected and captured in the electronic health record, which may have originally included errors in data entry leading to misclassification bias.

This study’s 9-year duration enabled the assessment of trends within this patient population. However, care evolved during this time such as changes in the ED processes and variations in the availability of outpatient resources. About half of the patients were missing BRACHA scores, possibly due to system changes and provider biases, which limit generalizability, yet the results related to this assessment of aggression remain significant. Finally, although hospital-based patient outcomes were assessed for those transported by EMS and police, the study is limited by a lack of knowledge of EMS or police interventions. Our outcomes represent surrogate markers of symptom severity and resource utilization that likely mirror the experience of EMS and police, but this cannot be confirmed and warrants further investigation.³¹

Conclusion

This retrospective cohort study, using hospital-based electronic health record data from patients ages 5 to 18 years evaluated for an acute MBH condition in 2 free-standing pediatric EDs spanning 9 years, found that MBH visits to pediatric EDs are increasing, with EMS and police transports of pediatric patients with acute MBH concerns now making up a sizable proportion of all transports. These patients represent a more potentially aggressive and ill subpopulation of pediatric MBH patients as they required more pharmacologic, physical, and mechanical restraints and were more likely to be admitted when compared to those who self-transported. Moreover, disparities in mental health resource access were evident, with an overrepresentation of Black and publicly insured patients among those requiring ED restraint and EMS or police assistance. Advocacy and educational interventions are imperative and necessary to equip prehospital clinicians and police officers with the skills and resources to effectively and safely manage pediatric MBH patients as they encounter this high-risk population with increasing frequency.

Supplementary Material

Supplementary Data

Supplementary data related to this article can be found in the online version at doi:10.1016/j.acap.2024.05.001.

WHAT’S NEW

With higher numbers of pediatric mental and behavioral health (MBH) patients transported by emergency medical services or police requiring emergency department interventions for agitation/aggression, this study demonstrates their high acuity. Notably unique, it includes pediatric MBH patients transported by police.