Journal Article Annotations
2017, 2nd Quarter

Medical Education

Annotations by Diana Robinson, MD
July 2017

National survey on pediatric acute agitation and behavioral escalation in academic inpatient pediatric care settings

Also of interest:

Beach SR, Taylor JB, Kontos N: Teaching psychiatric trainees to “think dirty”: uncovering hidden motivations and deception
Psychosomatics 2017 Apr 17 (Epub ahead of print)

The authors describe a three-part approach for resident education on identifying and managing deceptive patients including didactics, process rounds, and clinical experience. The didactics component includes three lecture hours spread out during the PGY1, PGY2, and PGY3/4 training years. The process rounds component is recommended to be carried out at least once per week on high intensity services such as consult-liaison, inpatient, and emergency psychiatry. At the author’s institution, they are done 2-3 times a week directly after morning sign-out and are facilitated by a faculty member facilitator that is not the unit director or program director. Finally, the “see one, do one, teach one” approach is used with junior residents accompanying attendings during confronting patients with attending support and debriefing. This system of teaching the residents to “think dirty” helps residents be aware of potential pathological and nonpathological reasons for patient deception, to manage their countertransference, to reduce resident burnout, and improve their empathy for patients. This is relevant to C-L because patient deception is commonly encountered in emergency and inpatient C-L services and can lead to strong physician countertransference that can increase physician burnout and reduce patient empathy if not productively managed.

PUBLICATION #1 — Medical Education

National survey on pediatric acute agitation and behavioral escalation in academic inpatient pediatric care settings

Malas N, Spital L, Fischer J, Kawai Y, Cruz D, Keefer P

Psychosomatics 2017; 58(3):299-306

BACKGROUND: Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management.

METHODS: In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent’s respective hospital.

RESULTS: Responses were obtained from 38 North American academic children’s hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management.

CONCLUSION: Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

On PubMed: Psychosomatics 2017; 58(3):299-306

Annotation

The finding: The authors conducted a survey of pediatric hospitalists and pediatric C-L psychiatrists in order to characterize how practice and training experience in PAABE were similar or different based on specialty and to determine if there were existing screening, communication, and evaluation and management strategies that were formalized in pediatric inpatient settings. A total of 47 responses from 38 North American academic children’s hospitals in 20 states were included. The most common associated factors of PAABE were primary mental illness (27%) followed by medical illness (22%), multifactorial (16%), autism spectrum disorder (14%), and developmental disability (12.4%). Interventions were highly varied including behavioral response teams (n=3), active guideline development (n=9), protocols for specific patient populations (n=3), and consultation with psychiatry (n=4), social work (n=2), and Child Life (n=2).

Strength and weaknesses: Strengths of this study were obtaining data in an area where there is minimal literature with little consensus. Limitations included a low response rate to the non-incentivized survey through two professional listservs and a short one-month window of response. The small sample size limited statistical analysis with subgroup analysis showing trends but no statistical significance.

Relevance: Despite the common occurrence and perceived importance of pediatric acute agitation in the inpatient setting, there is minimal formal training, screening, preventative strategies, interprofessional communication, and management strategies to target PAABE. C-L psychiatrists in hospital settings are commonly consulted for treatment recommendations for acute agitation and may even be part of organized inpatient agitation response teams, so it is valuable to get a sense of the current systems that are in place at hospitals nationwide.