Characteristics of pediatric behavioral health emergencies in the prehospital setting

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.


INTRODUC TI ON
Approximately 10% of emergency medical services (EMS) dispatches in the United States are related to mental and behavioral health disorders. 1Of those, approximately 7% are for children, amounting to over 110,000 EMS encounters in 2018. 2 About one in five children with behavioral health emergencies arrive at the emergency department (ED) by EMS, 3 and ED visits by children for behavioral health care are continuing to increase over time. 4,5diatric prehospital behavioral health transports require distinct considerations, including weight-based medication dosing, attention to the child's developmental level, and involvement of caretakers. 6Challenges specific to the prehospital environment include the confined space of the ambulance and limited available staff to assist in deescalation. 7][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. 12spite 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. 64][15] The fourth study, conducted in Florida from 2011 to 2016, found that 4% of pediatric prehospital behavioral health transports involved interventions such as sedative medication or physical restraint. 16ditionally, the systematic review found that only four U.S. states had protocols in place for prehospital management of pediatric behavioral health emergencies. 6rther characterization of pediatric behavioral health EMS encounters across the United States 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 United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.

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 data set. 17

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). 19CAMHD-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 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 either there is 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 nonpatient transport such as organ transport.
available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

K E Y W O R D S
behavioral health, mental health, pediatrics, physical restraint, prehospital care

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 setting 8,10,11 and/or are listed within state EMS protocols for pediatric behavioral health encounters (from Maryland, Utah, Rhode Island, and Michigan). 6 examined demographic, clinical, and EMS-related characteristics, which were chosen based on prior literature suggesting relevance to behavioral health EMS encounters. 2,13We 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). 22Patient 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. 20The "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 (Table SS1). 17A 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 nonfire, hospital, private nonhospital, tribal), EMS system organization status (nonvolunteer, 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 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.

Data 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.4][25] 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) and STATA 16.0 (StataCorp).

RE SULTS
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 by patients 12-17 years old, and 86.6% occurred in urban areas (Table 1 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 (Table SS3), factors that were significant remained consistent.

DISCUSS ION
In this retrospective cross-sectional study, we found that more than one 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 TA B L E 1 Sociodemographic and clinical characteristics of pediatric behavioral health EMS encounters.SS1.
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. 26,27In 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 28 ; 1.1% of pediatric behavioral EMS encounters in Florida 16 ; and 9% of pediatric behavioral EMS encounters in the Australian state of Victoria. 10Pediatric 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%), 23,24 despite limited staff in the prehospital setting who can engage in verbal deescalation and the lack of a secure environment such as a safe room. 7,29 identified variation in physical restraint use by demographic characteristics.We found that males were more likely to be restrained, which was similar to that found in prior studies on restraint use in the prehospital setting among adults, 2 in inpatient pediatric units, 30 and in EDs among children. 23,24In contrast, prior studies in inpatient psychiatric and medical units did not find differences in restraint use by sex, [31][32][33] which could be due to differences in the patient population, physical environment, or staff training.In the ED, it has been found that adolescents are more likely to be physically restrained than younger children, 23,24 while a meta-analysis of restraint use among inpatient mental health units found that younger children were more likely to be restrained. 30In the prehospital setting, we found increased odds of restraint use among patients Health care facility 9417 ( Note: Data are reported as n (%) or median (IQR).
Abbreviations: ALS, Advanced Life Support; BLS, Basic Life Support.

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. 34Additionally, 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, 23,25 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 Factors associated with sedative medication among pediatric behavioral health EMS encounters, multivariable logistic regression.ALS, Advanced Life Support; BLS, Basic Life Support.
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. 10 Children with autism spectrum disorder are more likely to visit the ED for a psychiatric condition than their peers, 35 highlighting a need to educate prehospital clinicians on working with children with neurodevelopmental disabilities, including autism spectrum disorder. 36Also, 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 deescalation techniques. 37 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 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%). 39Variation in data quality and documentation practices may also contribute to differences across EMS systems and regions. 40For instance, a mixed-methods study conducted in Michigan found that rates of missing and invalid data varied by agency and medical control area. 41duction 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. 42In 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. 43ditionally, the use of physical restraints has been associated with physical injuries to both patients and staff. 12,44These 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 the 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 deescalation 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. 45Since children often mirror the emotional states of their caretakers, EMS clinicians should strive to support caretakers during emergencies as well. 45ior system-level improvement work has largely focused on behavioral health emergencies within the ED setting, 46,47 but there are many opportunities to translate these efforts to the prehospital setting. 48Pediatric-specific protocols for management of behavioral health emergencies can be implemented in additional EMS agencies and states. 6Additionally, 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. 11 the hospital setting, multifaceted interventions have successfully decreased restraint use in children.0][51][52] 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 deescalation. 53Future 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.

LI M ITATI O N S
While NEMSIS provides a large sample of EMS encounters in the United States, 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, 40 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.

CON CLUS IONS
We found that more than one in 10 emergency medical services encounters for children are for behavioral health.Among pediatric behavioral health emergency medical services encounters, the use of sedative medications and physical restraint varies by patient and emergency medical services 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.
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 data set is deidentified and organized by individual EMS encounters rather than individual patients.The 2019 data set included 34,203,087 EMS activations submitted by 10,062 EMS agencies in 47 states and territories, while the 2020 data set included 43,488,767 EMS activations submitted by 12,319 EMS agencies in 50 states and territories. 18This study was reviewed and deemed non-human subjects research by the Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board.

F I G U R E 1
Encounter inclusion/ exclusion flow diagram.CAMHD-CS, Childhood and Adolescent Mental Health Disorders Classification System.

All included encounters Encounters with sedative medication use Encounters with restraint use Encounters with either sedative medication or restraint use
Note: Data are reported as n (%). a 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 Table TA B L E 2 EMS system characteristics of pediatric behavioral health EMS encounters.
38ctors associated with restraint use among pediatric behavioral health EMS encounters, multivariable logistic regression.ALS, Advanced Life Support; BLS, Basic Life Support.clinicianstrained in ALS relative to BLS, given that BLS-trained clinicians have a scope of practice which prohibits administration of sedative medications.38However, 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 dif-