P0601 - Medication and Physical Restraint Utilization Following Implementation of a Patient Behavioral Event Response Algorithm: a Retrospective Case-Control Analysis

Title: Medication and Physical Restraint Utilization Following Implementation of a Patient Behavioral Event Response Algorithm: a Retrospective Case-Control Analysis

Introduction: Acute agitation in pediatric patients in the emergency department (ED) and medical inpatient units carries significant risk for patients and staff members. Rates of patient behavioral events (PBE) are increasing. Staff members often lack training, resources, and providers often lack the experience and comfort with various treatment options. While evidence-based consensus guidelines exist for psycho-pharmacologic management of agitation in adult patients, the evidence in pediatric patients is limited. An algorithm was created and implemented at our institution that standardizes care and offers guidance for PBE management, including a scoring system, calming strategies, medication choices, and monitoring instructions.

Objective: This study aims to identify changes in medication and physical restraint utilization following implementation of the PBE Response Algorithm. We hypothesized that there would be a quantitative increase in medication utilization with a concurrent decrease in the need for physical restraint.

Methods: This is a retrospective case-control study comparing the frequency of patients in the pediatric ED and medical inpatient unit who received medications derived from the PBE response algorithm and who required physical restraint for the two years before and after implementation of the algorithm. Comparisons were made using chi-square statistics to determine differences in management by group.

Results: Utilization of both ziprasidone and olanzapine increased by 71% in the pediatric ED, from a rate of 8.9 to 15.3/10,000 patient visits and from 17.1 to 29.3/10,000 patient visits respectively, p-values < 0.05 (Figure 1). On the medical inpatient units, olanzapine utilization increased by 86%, from 3.5 to 6.5/1,000 patient admissions p-value of < 0.05 (Figure 2). Physical restraint utilization decreased by 12% in the Pediatric ED, from 15.8 to 14/10,000 patient visits and by 16% on the medical inpatient units, from 9.3 to 7.8/1,000 patient admissions; however, these differences did not reach statistical significance.

Discussion/

Conclusion: Over the past several years, there has been an increased frequency of pediatric PBEs. Our institution created a PBE response algorithm, standardizing management, which resulted in statistically significant increases in utilization of ziprasidone in the pediatric ED and olanzapine in both the pediatric ED and inpatient units. Haloperidol & lorazepam utilization were not significantly different, likely due to familiarity with these medications. A global decrease in physical restraint utilization and the percentage of patients receiving physical restraints without first receiving PBE medications was demonstrated, but was not statistically significant. Future steps will involve determining the frequency of PBE, doses needed per PBE, physician and nurse satisfaction with a supporting algorithm, and adverse drug events.