- Email: [email protected]
28.5 Consensus Guidelines for Pro Re Nata Medication for Agitation in the Emergency Department
CLINICAL PERSPECTIVES 28.3 — 28.5
28.3 DISCUSSION OF CLINICAL PATHWAYS FOR AGITATION Anik Jhonsa, MD, Children’s Hospital of Philadelphia, [email protected] Objectives: Agitation and aggression in pediatric settings can lead to disruption in care and lead to dangerous and harmful situations for patients and staff. This presentation aims to describe the role that clinical pathways can play in the management of agitated and aggressive behavior. Methods: Multidisciplinary teams worked together on the establishment of clinical pathways at The Children’s Hospital of Philadelphia aimed at providing clear and consistent means for approaching patients with behavioral difficulties. These pathways allow for care to be proactive when patients present to the hospital to attempt to minimize potential for harm. Results: Given that there are limited guidelines with regard to best practices for management of agitation and aggression in pediatric hospital settings, these clinical pathways can serve as a basis for approaching all patients. Establishment of clinical pathways allows for consistent delineation of responsibilities for all staff (nursing, front line clinicians, social work, etc.) to be involved in working with the patient from the time they arrive at the hospital. Our data have consistently shown that the majority of restraints in the pediatric emergency departments occur within the first 30 minutes of a patient arriving before any mental health providers are involved in the case. Our clinical pathways have allowed us to empower frontline non-mental health providers to assess patients and provide interventions to allow for immediate intervention to reduce episodes of agitation and aggression. Additionally, these pathways provide firmer guidelines to frontline providers for when (and when not) to proceed with pharmacologic intervention and what strategies should be attempted before administration of medication. Conclusions: Agitated and aggressive behavior can be difficult to manage in pediatric settings that are not often accustomed to routinely dealing with similar events. Establishment and implementation of clinical pathways provide pediatric teams with firm guidelines for ways to approach care. This can often lead to de-escalation of situations that, in the past, would have required pharmacologic intervention or physical restraint.
AGG, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.167
28.4 PEDIATRIC AGITATION MANAGEMENT IN THE PSYCHIATRIC EMERGENCY DEPARTMENT: THE EVIDENCE BASE Megan Mroczkowski, MD, Columbia University Medical Center, [email protected] Objectives: Annually, 30 million children present to emergency departments (EDs); three to four percent present with behavioral health chief complaints, such as agitation; 15 percent of patients with agitation are restrained, and 23 percent of patients with autism spectrum disorder (ASD) are restrained or sedated. This section investigates how agitation/aggression is treated in the pediatric ED setting and asks whether there is a standard practice or evidence-or empirical-drive practice. Methods: A literature search was conducted using publications in Medline and PsycINFO from January 1, 1996 to January 1, 2017. This yielded 906 results. A study was included if the patients were less than age 18 years, the patient had agitation or aggression, the topic was psychopharmacological management, and the management was acute. Studies were excluded if the topic was nonpsychopharmacological treatment strategies. Results: There are no RCTs for agitation or aggression in pediatric EDs; the majority of studies were case-control, retrospective chart reviews, and case reports. The following classes of medications will be described,
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
along with the evidence guiding their support: 1) antihistamines (one RCT of PRN diphenhydramine vs. placebo); 2) benzodiazepines (no studies identified the use of benzodiazepines for this indication); 3) typical antipsychotic drugs (haloperidol: RCT and haloperidol vs. lithium); 4) atypical antipsychotic drugs [risperidone: RCT on an inpatient unit, two RCTs for the intellectually disabled patients; olanzapine: open-label, prospective study; intramuscular (IM) ziprasidone vs. IM olanzapine, retrospective chart review; ziprasidone vs. IM haloperidol and IM lorazepam]; 5) stimulants (RCT of methylphenidate extended-release tablets vs. methylphenidate using aggression as secondary outcome measure); 6) mood stabilizers (lithium: RCT on inpatient unit); and 7) antidepressants (bupropion: four-site RCT). The most recent Consensus Guidelines for this topic will be discussed: Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY) Parts I and II (2003) and the Treatment of Maladaptive Aggression in Youth: CERT Guidelines I and II (2012). Conclusions: There are four FDA-approved medications for agitation/ aggression; two of these are for patients with ASD. Atypical antipsychotic drugs have the largest effect size, followed by stimulants and typical antipsychotic drugs.
AGG, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.168
28.5 CONSENSUS GUIDELINES FOR PRO RE NATA MEDICATION FOR AGITATION IN THE EMERGENCY DEPARTMENT Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: More and more youth are presenting to emergency departments (EDs) in psychiatric distress. Many of these youth present with agitated behavior or aggression as a result of psychosis, anxiety, mania, intoxication, or in relation to underlying behavioral disorder. Agitated patients can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and efficacy of PRN medications to treat or prevent acute agitation. In the absence of evidence-based guidelines, expert guidance is needed to assist clinicians in choosing effective and appropriate PRN medications for acute agitation. Methods: The Delphi method for consensus guideline development was used by a team of ED-based child and adolescent psychiatrists from across the United States. By use of an iterative, blinded process to reduce bias, participants reviewed existing or published PRN medication algorithms and guidelines for acute agitation and then developed consensus guidelines with identification of areas of dissension and need for further research. Results: There were significant variations in preferred medications across geography and type of ED setting (medical vs. psychiatric ED). Participants emphasized the importance of nonpharmacologic de-escalation strategies; clinical diagnostic assessment, even in the moment of acute agitation; consideration of individual patient factors in choosing medications; and careful monitoring for efficacy and adverse effects. A range of medications, including antipsychotic drugs, antihistamine, benzodiazepine, and a-adrenergic medications, was recommended. Conclusions: There are currently no AACAP Practice Parameters for the psychopharmacological management of agitation, and there is little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. Expert consensus guidelines such as these provide much-needed guidance to ED clinicians. These guidelines also demonstrate areas where further research is needed, especially into the comparative efficacy of different PRN medications in patients of different ages, clinical presentations, and diagnostic/treatment history.
ADOL, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.169
www.jaacap.org
S43
28.3 DISCUSSION OF CLINICAL PATHWAYS FOR AGITATION Anik Jhonsa, MD, Children’s Hospital of Philadelphia, [email protected] Objectives: Agitation and aggression in pediatric settings can lead to disruption in care and lead to dangerous and harmful situations for patients and staff. This presentation aims to describe the role that clinical pathways can play in the management of agitated and aggressive behavior. Methods: Multidisciplinary teams worked together on the establishment of clinical pathways at The Children’s Hospital of Philadelphia aimed at providing clear and consistent means for approaching patients with behavioral difficulties. These pathways allow for care to be proactive when patients present to the hospital to attempt to minimize potential for harm. Results: Given that there are limited guidelines with regard to best practices for management of agitation and aggression in pediatric hospital settings, these clinical pathways can serve as a basis for approaching all patients. Establishment of clinical pathways allows for consistent delineation of responsibilities for all staff (nursing, front line clinicians, social work, etc.) to be involved in working with the patient from the time they arrive at the hospital. Our data have consistently shown that the majority of restraints in the pediatric emergency departments occur within the first 30 minutes of a patient arriving before any mental health providers are involved in the case. Our clinical pathways have allowed us to empower frontline non-mental health providers to assess patients and provide interventions to allow for immediate intervention to reduce episodes of agitation and aggression. Additionally, these pathways provide firmer guidelines to frontline providers for when (and when not) to proceed with pharmacologic intervention and what strategies should be attempted before administration of medication. Conclusions: Agitated and aggressive behavior can be difficult to manage in pediatric settings that are not often accustomed to routinely dealing with similar events. Establishment and implementation of clinical pathways provide pediatric teams with firm guidelines for ways to approach care. This can often lead to de-escalation of situations that, in the past, would have required pharmacologic intervention or physical restraint.
AGG, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.167
28.4 PEDIATRIC AGITATION MANAGEMENT IN THE PSYCHIATRIC EMERGENCY DEPARTMENT: THE EVIDENCE BASE Megan Mroczkowski, MD, Columbia University Medical Center, [email protected] Objectives: Annually, 30 million children present to emergency departments (EDs); three to four percent present with behavioral health chief complaints, such as agitation; 15 percent of patients with agitation are restrained, and 23 percent of patients with autism spectrum disorder (ASD) are restrained or sedated. This section investigates how agitation/aggression is treated in the pediatric ED setting and asks whether there is a standard practice or evidence-or empirical-drive practice. Methods: A literature search was conducted using publications in Medline and PsycINFO from January 1, 1996 to January 1, 2017. This yielded 906 results. A study was included if the patients were less than age 18 years, the patient had agitation or aggression, the topic was psychopharmacological management, and the management was acute. Studies were excluded if the topic was nonpsychopharmacological treatment strategies. Results: There are no RCTs for agitation or aggression in pediatric EDs; the majority of studies were case-control, retrospective chart reviews, and case reports. The following classes of medications will be described,
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
along with the evidence guiding their support: 1) antihistamines (one RCT of PRN diphenhydramine vs. placebo); 2) benzodiazepines (no studies identified the use of benzodiazepines for this indication); 3) typical antipsychotic drugs (haloperidol: RCT and haloperidol vs. lithium); 4) atypical antipsychotic drugs [risperidone: RCT on an inpatient unit, two RCTs for the intellectually disabled patients; olanzapine: open-label, prospective study; intramuscular (IM) ziprasidone vs. IM olanzapine, retrospective chart review; ziprasidone vs. IM haloperidol and IM lorazepam]; 5) stimulants (RCT of methylphenidate extended-release tablets vs. methylphenidate using aggression as secondary outcome measure); 6) mood stabilizers (lithium: RCT on inpatient unit); and 7) antidepressants (bupropion: four-site RCT). The most recent Consensus Guidelines for this topic will be discussed: Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY) Parts I and II (2003) and the Treatment of Maladaptive Aggression in Youth: CERT Guidelines I and II (2012). Conclusions: There are four FDA-approved medications for agitation/ aggression; two of these are for patients with ASD. Atypical antipsychotic drugs have the largest effect size, followed by stimulants and typical antipsychotic drugs.
AGG, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.168
28.5 CONSENSUS GUIDELINES FOR PRO RE NATA MEDICATION FOR AGITATION IN THE EMERGENCY DEPARTMENT Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: More and more youth are presenting to emergency departments (EDs) in psychiatric distress. Many of these youth present with agitated behavior or aggression as a result of psychosis, anxiety, mania, intoxication, or in relation to underlying behavioral disorder. Agitated patients can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and efficacy of PRN medications to treat or prevent acute agitation. In the absence of evidence-based guidelines, expert guidance is needed to assist clinicians in choosing effective and appropriate PRN medications for acute agitation. Methods: The Delphi method for consensus guideline development was used by a team of ED-based child and adolescent psychiatrists from across the United States. By use of an iterative, blinded process to reduce bias, participants reviewed existing or published PRN medication algorithms and guidelines for acute agitation and then developed consensus guidelines with identification of areas of dissension and need for further research. Results: There were significant variations in preferred medications across geography and type of ED setting (medical vs. psychiatric ED). Participants emphasized the importance of nonpharmacologic de-escalation strategies; clinical diagnostic assessment, even in the moment of acute agitation; consideration of individual patient factors in choosing medications; and careful monitoring for efficacy and adverse effects. A range of medications, including antipsychotic drugs, antihistamine, benzodiazepine, and a-adrenergic medications, was recommended. Conclusions: There are currently no AACAP Practice Parameters for the psychopharmacological management of agitation, and there is little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. Expert consensus guidelines such as these provide much-needed guidance to ED clinicians. These guidelines also demonstrate areas where further research is needed, especially into the comparative efficacy of different PRN medications in patients of different ages, clinical presentations, and diagnostic/treatment history.
ADOL, CON, EBP http://dx.doi.org/10.1016/j.jaac.2017.07.169
www.jaacap.org
S43