Pre-post implementation study of a medication-focused order set for management of acute agitation in a pediatric emergency department

Purpose: To assess changes in prescribing practice after implementation of a medication-focused order set for acute agitation management in a pediatric emergency department (ED). Methods: Patients 5 to 18 years of age who presented to the St. Louis Children’s Hospital ED for behavioral health concerns between September 1, 2020, and October 31, 2022, were included. Chlorpromazine, clonidine, diphenhydramine, haloperidol, lorazepam, olanzapine, and/or risperidone administrations, including dose, route, frequency, and automated dispensing cabinet (ADC) overrides, were evaluated per ED patient encounter. Physical restraint orders were also assessed. Results: We identified 3,756 patient encounters; 1,742 were included in the preimplementation group and 2,014 in the postimplementation group. The proportion of ED encounters with medication administration and the number of medications administered per encounter did not differ significantly between the 2 groups. There was an increase in the frequency of ED patient encounters with olanzapine and chlorpromazine administration after order set implementation, whereas haloperidol and lorazepam administration decreased. The percentage of patient encounters with standing pro re nata medications orders increased in the postimplementation period, while there were decreases in ADC overrides, combination therapy administration, and duration of physical restraint use per ED encounter. Conclusion: Prescribing practices, including medication selection, ordered frequency, ADC overrides, and combination therapy, differed following the implementation of a medication-focused order set for acute agitation. Transitioning to empiric oral and intramuscular olanzapine as first-line therapy, diphenhydramine as second-line therapy, and olanzapine as third-line therapy did not increase the rate of medication administration or utilization of subsequent lines of therapy. Additional studies are needed to better understand individualized response, adverse effects, and the incidence of oversedation with pharmacotherapy for acute agitation management in pediatric patients in the ED setting.