Psychotropic Medication Administration in Pediatric Emergency Departments Free

We conducted a retrospective cross-sectional study of ED visits to children’s hospitals in the Pediatric Health Information System (PHIS) by patients aged 3 to 21 years with a primary diagnosis of a MBH condition, from 2013 to 2022. PHIS is an administrative database containing inpatient, ED, ambulatory surgery, and observation encounter-level data from more than 49 not-for-profit, tertiary care children’s hospitals in the United States that are affiliated with the Children’s Hospital Association (Lenexa, KS). Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. Portions of the data submission and data quality processes for the PHIS database are managed by Truven Health Analytics (Ann Arbor, MI).¹⁴  Data are deidentified at the time of data submission and are subjected to multiple reliability and validity checks before inclusion in the database. For this study, data from 34 hospitals with complete discharge and billing data available for the entire study period were included.

ED visits were included for youth aged 3 to 21 years with MBH conditions, identified using International Classification of Disease, Ninth Revision and International Classification of Disease, Tenth Revision codes and grouped using a previously validated classification system (Supplemental Table 3).^15 –17  ED encounters with a primary diagnosis code in any of the 30 MBH diagnosis groupings were included.

Study measures included age in years (groupings 3–7, 8–12, 13–17, 18–21 based on prior literature),¹⁵  sex (male, female), race and ethnicity (non-Hispanic white, non-Hispanic Black, Hispanic, Asian, other), insurance type (private, public, other), and ED disposition (transfer to another medical facility, admission, discharge from the ED, leaving against medical advice, or death). Of note, recognizing that race and ethnicity are a social construct, race and ethnicity were included in demographic data and analysis because of known disparities deriving from structural racism.¹⁶  More specifically, there are known racial disparities in delivery of pediatric MBH care.^15,17  Children with complex chronic conditions were identified using an established set of diagnosis codes,¹⁸  and were included in the analysis due to prior literature on increased adverse medication events within the ED setting.¹⁹  A child with complex chronic conditions is defined as, “Any medical condition that can be reasonably expected to last at least 12 months (unless death intervenes) and to involve either several different organ systems or 1 organ system severely enough to require specialty pediatric care and probably some period of hospitalization in a tertiary care center.”²⁰ 

We defined psychotropic medication administration based on the presence of a Clinical Transaction Classification billing code in 1 of the following categories: psychotherapeutic (antianxiety, antidepressants, antipsychotics, antipsychotic combinations), stimulants, anticonvulsants, antihistamines, antihypertensives, and other (Supplemental Table 4). Categories were specified based on prior literature examining treatment of MBH conditions in children and adolescents.^6,8,21,22  We included medications administered at any time during the ED encounter for patients discharged or transferred. For admitted patients, we included medications administered on day 1 or 2, as medication timing was specified in the data set only by calendar day of the visit and not by hour or setting of administration (ED versus inpatient).^5,15 

We described the frequency of psychotropic medication administration, overall and by medication category type. To test trends in the proportion of MBH encounters with psychotropic medication use, we estimated a logistic regression model with medication use as the dependent variable and both linear and quadratic terms for time (coded as the year of visit) as the independent variable. If the quadratic term was not statistically significant, we removed it and reestimated the model. We constructed similar models for each specific medication category. Logistic regression models used robust SEs clustered on hospital to account for intra-hospital correlation. Models for which an effect estimate was produced were assessed for collinearity and all variables were retained.

To test changes in the total quantity of psychotropic medication use over time, we estimated a Poisson regression with total amount of medications given as the dependent variable and year as the independent variable. This test used robust SEs and included hospital as a covariate to deal with the nonindependence, and we reported the resulting incidence rate ratios.

Finally, to assess hospital-level variation in psychotropic medication use, we estimated a logistic regression model with medication use as the dependent variable and hospital (modeled as a set of indicator variables) as the independent variable and a Poisson regression with total medications administered as the dependent variable and hospital (modeled as a set of indicator variables) as the independent variable. For both models, we tested the null hypothesis that the outcomes were equal across all hospitals using a Wald test. Additional analysis of changes in medication administration among hospitals between 2013 and 2019 and 2021 and 2022 was performed. Sensitivity analysis of first-time visits only was conducted yielding similar results, therefore was not included. Effect estimates were reported as odds ratios (OR) with 95% confidence intervals (CI). All statistical tests were 2-tailed, and α was set at 0.05. Data analyses were performed using Stata version 17.0 (Stata Corp). This study was deemed exempt by the institutional review board at Boston Children’s Hospital.

During the 10-year study period, there were 670 911 ED encounters by youth with a primary MBH diagnosis, of which 12.3% had psychotropic medication administered (Table 1). ED MBH encounters were most commonly children aged 13 to 17 years (62.8%), female (57.5%), white (59.2%), non-Hispanic (75.8%), publicly insured (53.3%), and discharged (60.6%). The most common mental health diagnoses groupings were depressive disorder (24.9%), suicide or self-injury (22.9%), and disruptive, impulse control and conduct disorders (9.4%) (Supplemental Table 6). The diagnosis grouping with the highest frequency of psychotropic medication administration was intellectual disability (25.4%) followed by autism spectrum disorder (25.3%). Across psychotropic medication categories, antipsychotic and antipsychotic combinations were the most frequently administered (Supplemental Table 7).

The percentage of MBH encounters with at least 1 psychotropic medication increased from 7.9% in 2013 to 16.3% in 2022, with the odds of administration increasing each year (OR, 1.09; 95% CI, 1.05–1.13) (Fig 1). Encounters for all ages that involved administration of each psychotropic medication category increased significantly over time, except for antianxiety medications (Table 2). For the youngest age grouping, significant increases were noted for categories of stimulant (OR, 1.12; 95% CI, 1.04–1.21), antihypertensive (OR, 1.10; 95% CI, 1.03–1.16), antihistamine (OR, 1.06; 95% CI, 1.02–1.10), and antipsychotic and antipsychotic combination medications (OR, 1.05; 95% CI, 1.01–1.09) (Supplemental Table 5).

The total number of psychotropic medications administered during ED MBH encounters increased from 6652 in 2013 to 48 174 in 2022, representing a 624% increase across the study period, with significant annual increases (incidence rate ratio, 1.11; 95% CI, 1.09–1.15). Across hospitals, psychotropic medication use varied from 4.2% to 23.1% of MBH encounters (P < .001; see Fig 2, right y-axis). Also, the total number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001; see Fig 2, left y-axis). Variability among hospitals was also appreciated in the change in percentage of psychotropic medications administered between 2013 to 2019 compared with 2021 to 2022 (Supplemental Fig 3).

In this 10-year study including 34 children’s hospitals, 12.3% of ED encounters by youth for an MBH condition had a psychotropic medication administered. Across the study period, the proportion of MBH encounters with at least 1 psychotropic medication administered doubled, and the total number of psychotropic medications administered in the ED increased nearly sevenfold. Across hospitals, the proportion of MBH encounters with psychotropic medication significantly varied from 1 in 25 to nearly 1 in 4 visits.

In contrast to previous literature that found no change to psychotropic medication use in the ED over time, we found significant increases over time.¹³  This could be due to the difference in included hospitals (children’s EDs) or inclusion of more recent years of study. Because some medications administered may be home medications, the increase could also reflect growth in outpatient prescribing of psychotropic medications among youth with MBH conditions.²³  Additionally, the increase in psychotropic medication administration may reflect increased severity or complexity of psychiatric illness in children over time. This trend is particularly evident since the start of the COVID-19 pandemic, with data reflecting a rise in requested mental health consults for children who were admitted to the hospital, and an increase in psychiatric hospitalizations for children with MBH conditions.^24,25 

Despite this increase in psychotropic medication administration in the ED, there is a paucity of evidence delineating the effectiveness and safety of medications intended to manage acute MBH symptoms in children, with current guidelines derived from expert consensus rather than high quality, prospective trials.⁸  In fact, the limited available evidence suggests that pro re nata (PRN) medications for acute behavioral outbursts may not be effective.^26,27  Additionally, there are adverse effects associated with PRN psychotropic administration including acute dystonia/motor reactions, drowsiness, confusion, increased seizure frequency, agitation, and bizarre behavior.²⁷  Emergency department team education around psychotropic medications could aid in early recognition and treatment of adverse effects from PRN medications. Additional research is also needed to develop and test strategies to reduce disparities in psychotropic medication administration by race and ethnicity.¹⁵  Further study is needed to compare effectiveness and safety of medications for acute MBH symptoms within the ED setting.

Increases in psychotropic medication utilization may also result from longer lengths of stay within the ED while youth are awaiting inpatient psychiatric care, termed ED boarding.⁴  Both children and ED staff are negatively impacted by ED boarding; qualitative studies report moral distress in ED staff because of barriers in care delivery and an inability to meet the basic needs of children who are boarding (such as preferred meal options, daily hygiene, and limited therapeutic support).^28,29  Additionally, ED boarding may actually worsen MBH symptoms, leading to further medication administration.²⁸  Although new standing medications are not commonly started for children as part of a mental health intervention while boarding,³⁰  they do receive psychotropic home medications and PRN medications to address acute psychiatric or behavioral symptoms.^4,5,26  Increased medication administration during ED boarding strains already limited ED resources.^31,32  Furthermore, the risk of medication errors is substantial,^10,33  with a single-center study reporting that 72.1% of 671 children undergoing MBH boarding in the ED experienced a medication error.¹¹  Since the start of the COVID-19 pandemic, rates and duration of MBH ED boarding continues to increase, likely because of an ongoing shortage of pediatric-trained mental health professionals, limited outpatient mental health resources, and decreased pediatric psychiatric inpatient capacity.^34 –37  Greater resources and support both internal and external to the ED are urgently needed to promote safe and patient-centered care.^28,37 

We also found significant variation in psychotropic medication administration across children’s hospitals. Variability among hospitals was also appreciated when comparing changes in medication administration before the COVID-19 pandemic (2013–2019) to after the pandemic had started (2021–2022). Variation among hospitals may be due to differing ED resources, such as the presence of standardized care pathways, specialized behavioral health response teams, or availability of pediatric-trained mental health professionals.³⁸  Furthermore, variation may be due to lack of high-quality evidence to guide appropriate psychotropic medication use in the ED setting. Variability in clinical practice has been associated with negative outcomes including unnecessary resource utilization, increased revisit rates, and hospitalizations for other emergent conditions.^39 –42  Future studies could evaluate why some hospitals have high or low psychotropic medication use, including how ED characteristics and resources differ among these hospitals.

Our study has several limitations. When using an administrative database, diagnoses and demographic characteristics may be misclassified. Additionally, we could not discern if medications were previously prescribed (home) medications or used to treat acute mental health symptoms. Furthermore, medications were identified based on billing codes, meaning that we could not confirm if medications were successfully administered. For encounters resulting in admission, psychotropic medications ordered within the first 2 days of care were attributed to the ED, although it is possible some medications were administered after admission. Additionally, the PHIS database cannot distinguish the following during the ED encounter: hours spent ED boarding, if the identified need for emergency services exceeds available resources for patient care (ED crowding), ED staffing, or severity of patient mental health symptoms. Finally, because the PHIS database only includes freestanding, tertiary care academic children’s hospitals, findings may not be generalizable to MBH encounters at other hospital types such as community hospitals. Despite this limitation, MBH encounters are increasing across all EDs regardless of type, and all EDs face similar challenges around increasing medication utilization.

Over a 10-year period, for children in the ED with MBH diagnoses, both psychotropic medication administration and the proportion of encounters with at least 1 psychotropic medication given significantly increased. Additionally, psychotropic medication utilization significantly varied across the 34 included children’s hospitals. Further study into factors associated with psychotropic medication use could minimize risk of adverse medication-related events and ensure standardization of care.

CI

confidence interval

ED

emergency department

MBH

mental and behavioral health

OR

odds ratios

PHIS

Pediatric Health Information System

PRN

pro re nata