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Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use.To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals.We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared.Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis.Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

The financial impact of the rising number of pediatric mental health hospitalizations is unknown. Therefore, this study assessed costs, reimbursements, and net profits or losses for 111,705 mental health and non–mental health medical hospitalizations in children’s hospitals with use of the Pediatric Health Information System and Revenue Management Program. Average financial margins were calculated as (reimbursement per day) – (cost per day), and they were lowest for mental health hospitalizations ($136/day), next lowest for suicide attempt ($518/day), and highest for other medical hospitalizations ($611/day). For 10 of 17 hospitals, margin per day for mental health hospitalizations was lower than margin per day for other medical hospitalizations. For these 10 hospitals, the total net loss for inpatient and observation status mental health hospitalizations, compared with other medical hospitalizations, was $27 million (median, $2.2 million per hospital). Financial margins were usually lower for mental health vs non–mental health medical hospitalizations. Journal of Hospital Medicine 2020;15:727- 730. © 2020 Society of Hospital Medicine

* Abbreviations: ED — : emergency department ICD-10 — : International Classification of Diseases, 10th Revision PHIS — : Pediatric Health Information System SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 In the United States, 4.6 million children live in a home with an unsecured firearm, increasing their risk for firearm-related injuries, which are the second leading cause of death in US children.1,2 In 2020, the United States witnessed an unprecedented rise in firearm sales as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic strained communities with additional psychosocial and economic stressors.3 Current literature evaluating firearm injuries and the SARS-CoV-2 pandemic includes only single-center data, adult populations, or young children, excluding pediatric suicide.4,5 We aimed to quantify pediatric firearm-related and total encounters during the initial 2020 SARS-CoV-2 pandemic period, as compared to these periods in the previous 3 years. We used International Classification of Diseases, 10th Revision (ICD-10) discharge diagnosis codes to conduct a cross-sectional comparison of pediatric (age 0–18 years) firearm-related and total emergency department (ED) and hospital encounters between calendar weeks 9 and 36 (corresponding to approximately March to August) 2020 and 2017–2019 at 44 US children’s hospitals participating in the Pediatric Health Information System (PHIS) database. The primary outcome was firearm-related encounters, defined as an initial encounter for a penetrating injury from a powder-charged weapon identified by … Address correspondence to Kelsey A.B. Gastineau, MD, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, 2200 Children’s Way, Nashville, TN 37232-9452. E-mail: kelsey.gastineau{at}vumc.org

OBJECTIVE: To evaluate associations of race/ethnicity and social determinants with 90-day rehospitalization for mental health conditions to acute care non-psychiatric children’s hospitals. STUDY DESIGN: We conducted a retrospective cohort analysis of mental health hospitalizations for children aged 5 to 18 years from 2016-2018 at 32 freestanding U.S. children’s hospitals using the Children’s Hospital Association’s Pediatric Health Information System (PHIS) database to assess the association of race/ethnicity and social determinants (insurance payer, neighborhood median household income, and rurality of patient home location) with 90-day rehospitalization. Risk factors for rehospitalization were modeled using mixed-effects multivariable logistic regression. RESULTS: Among 23,556 index hospitalizations, there were 1382 mental health rehospitalizations (5.9%) within 90 days. Non-Hispanic Black children were 26% more likely to be rehospitalized than non-Hispanic White children (adjusted odds ratio [aOR] 1.26, 95% CI 1.08-1.48). Those with government insurance were 18% more likely to be rehospitalized than those with private insurance (aOR 1.18, 95% CI 1.04-1.34). In contrast, those living in a suburban location were 22% less likely to be rehospitalized than those living in an urban location (suburban: aOR 0.78, 95% CI 0.63-0.97). CONCLUSIONS: Non-Hispanic Black children and those with public insurance were at highest risk for 90-day rehospitalization, and risk was lower in those residing in suburban locations. Future work could focus on upstream interventions that will best attenuate social disparities to promote equity in pediatric mental healthcare.