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 United States, 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.

Methods: We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their 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 toward 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.

Conclusions: 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.

Keywords: acute agitation; aggression; emergency department; mental health; pediatrics; workplace violence.