Core Competencies

3.01 Specialized Services: Acute Behavioral and Psychiatric Conditions

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Knowledge

Pediatric hospitalists should be able to:

  • State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
  • Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
  • Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
  • State indications for intra- or interfacility transfer, attending to local context and resource needs.
  • Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
  • Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
  • Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
  • Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
  • Review common acute behavioral concerns that may occur in children with autism or developmental delays.
  • Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
  • Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
  • List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
  • Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
  • Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
  • Discuss the approach toward a successful interdisciplinary family meeting for this population.

Skills

Pediatric hospitalists should be able to:

  • Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
  • Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
  • Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
  • Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
  • Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
  • Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
  • Demonstrate basic skills in de-escalating aggression in patients.
  • Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
  • Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
  • Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
  • Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
  • Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Attitudes

Pediatric hospitalists should be able to:

  • Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
  • Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
  • Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
  • Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
  • Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
  • Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
  • Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
  • Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

References

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