Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals

Abstract

Background: Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use.

Objective: To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals.

Design, setting, and participants: We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared.

Results: Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis.

Conclusions: Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

FIGURE 1

Adjusted and unadjusted pharmacologic restraint use by hospital. Covariates adjusted for include DSM-V category, CCC, ICU stay, length of stay, H-RISK, age, sex, payor, and hospital disposition. CCC, complex chronic conditions; DSM-V, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; H-RISK, Hospitalization Resource Intensity Scores for K; ICU, intensive care unit.

FIGURE 2

Heatmap and cluster analysis of pharmacologic restraint use. Hospitals are sorted by highest to lowest overall use with the cluster number indicated. Overall drug use and drug use by class are displayed as columns. Color values correspond to use quartiles, with red shading indicating higher use, followed by orange, yellow, and finally, green shading indicating lower use.