Mental Health Revisits at US Pediatric Emergency Departments

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions

OBJECTIVE

We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported.

METHODS

This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends.

RESULTS

Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001).

CONCLUSIONS

Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.

Identifying Precise Targets to Improve Child Mental Health Care Equity: Leveraging Advances in Clinical Research Informatics and Lived Experience

To reduce child mental health disparities, it is imperative to improve the precision of targets and to expand our vision of social determinants of health as modifiable. Advancements in clinical research informatics and please state accurate measurement of child mental health service use and quality. Participatory action research promotes representation of underserved groups in informatics research and practice and may improve the effectiveness of interventions by informing research across all stages, including the identification of key variables, risk and protective factors, and data interpretation.

Approach to acute agitation in the pediatric emergency department

PURPOSE OF REVIEW

The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED.

RECENT FINDINGS

Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time.

SUMMARY

Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.

Pandemic Planning, Response, and Recovery for Pediatricians: A Focus on Health Equity and Social Determinants of Health

This article summarizes how pediatricians may be uniquely positioned to mitigate the long-term trajectory of COVID-19 on the health and wellness of pediatric patients especially with regard to screening for social determinants of health that are recognized drivers of disparate health outcomes. Health inequities, that is, disproportionately deleterious health outcomes that affect marginalized populations, have been a major source of vulnerability in past public health emergencies and natural disasters. Recommendations are provided for pediatricians to collaborate with disaster planning networks and lead strategies for public health communication and community engagement in pediatric pandemic and disaster planning, response, and recovery efforts.

Vulnerable Hours of the Day for Severe Iatrogenic Hypoglycaemia in Type 2 Diabetes: A Single-Centre Retrospective Study

INTRODUCTION

Iatrogenic hypoglycaemia is an event that should be avoided in the treatment of diabetes, but the pathophysiology thereof has been poorly examined and reported. There is no established method for preventing iatrogenic hypoglycaemia and the current approach is a reactive response following onset of the disease. In this study, we aimed to explore the existence of 'hypoglycaemia-vulnerable hours of the day' in patients with type 2 diabetes, with the ultimate goal of preventing the onset of iatrogenic hypoglycaemia by clarifying the time when severe hypoglycaemia is likely to occur.

METHODS

Of the 553,201 patients who visited the Critical Care and Emergency Center of Aizawa Hospital between 2008 and 2019, patients with proven hypoglycaemia (blood glucose level <3.0 mmol/L) and those using insulin or oral hypoglycaemic agents for the treatment of type 2 diabetes were included: 146 insulin users and 148 oral hypoglycaemic agent users. Cosinor analysis was employed to identify hypoglycaemia-vulnerable hours of the day.

RESULTS

Patients with type 2 diabetes and severe hypoglycaemia had two peaks: at 8:00 and 18:00-19:00. Hypoglycaemia was observed as quadra-peaked in insulin users and double-peaked in oral hypoglycaemic agent users. Single-cosinor analysis revealed that the cycle was 5.83 hours (R=0.417) in insulin users, whereas it was 11.0 hours (R=0.717) in oral hypoglycaemic agent users. In insulin users, a significant periodicity of six hours (P=0.003) was observed in the cosinor detection analysis, and a significant correlation (P<0.05) was present in the cosinor percent rhythmicity analysis. In contrast, in oral hypoglycaemic agent users, a significant periodicity of 11 hours (P=0.03) was ascertained in the cosinor detection analysis, and there was a significant correlation (P<0.001) in the cosinor percent rhythmicity analysis. There were different hypoglycaemia-vulnerable hours of the day in the patients with type 2 diabetes, suggesting an interaction between disease pathophysiology and pharmacology.

CONCLUSIONS

These results can help elucidate the trend of the development of iatrogenic hypoglycaemia and contribute to the prevention of the onset thereof.

Brief Interventions for Suicidal Youths in Medical Settings: A Meta-Analysis

CONTEXT

Most youths who die by suicide have interfaced with a medical system in the year preceding their death, placing outpatient medical settings on the front lines for identification, assessment, and intervention.

OBJECTIVE

Review and consolidate the available literature on suicide risk screening and brief intervention with youths in outpatient medical settings and examine common outcomes.

DATA SOURCES

The literature search looked at PubMed, OVID, CINAHL, ERIC, and PsychInfo databases.

STUDY SELECTION

Interventions delivered in outpatient medical settings assessing and mitigating suicide risk for youths (ages 10-24). Designs included randomized controlled trials, prospective and retrospective cohort studies, and case studies.

DATA EXTRACTION

Authors extracted data on rates of referral to behavioral health services, initiation/adjustment of medication, follow-up in setting of assessment, suicidal ideation at follow-up, and suicide attempts and/or crisis services visited within 1 year of initial assessment.

RESULTS

There was no significant difference in subsequent suicide attempts between intervention and control groups. Analysis on subsequent crisis service could not be performed due to lack of qualifying data. Key secondary findings were decreased immediate psychiatric hospitalizations and increased mental health service use, along with mild improvement in subsequent depressive symptoms.

LIMITATIONS

The review was limited by the small number of studies meeting inclusion criteria, as well as a heterogeneity of study designs and risk of bias across studies.

CONCLUSIONS

Brief suicide interventions for youth in outpatient medical settings can increase identification of risk, increase access to behavioral health services, and for crisis interventions, can limit psychiatric hospitalizations.

Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic

Importance

Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources.

Objective

To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively.

Exposure

The COVID-19 pandemic.

Main outcomes and measures

The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit.

Results

Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%).

Conclusions and relevance

Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.

Comparison of Administrative Database-Derived and Hospital-Derived Data for Monitoring Blood Culture Use in the Pediatric Intensive Care Unit

BACKGROUND

Optimizing blood culture practices requires monitoring of culture use. Collecting culture data from electronic medical records can be resource intensive. Our objective was to determine whether administrative data could serve as a data source to measure blood culture use in pediatric intensive care units (PICUs).

METHODS

Using data from a national diagnostic stewardship collaborative to reduce blood culture use in PICUs, we compared the monthly number of blood cultures and patient-days collected from sites (site-derived) and the Pediatric Health Information System (PHIS, administrative-derived), an administrative data warehouse, for 11 participating sites. The collaborative's reduction in blood culture use was compared using administrative-derived and site-derived data.

RESULTS

Across all sites and months, the median of the monthly relative blood culture rate (ratio of administrative- to site-derived data) was 0.96 (Q1: 0.77, Q3: 1.24). The administrative-derived data produced an estimate of blood culture reduction over time that was attenuated toward the null compared with site-derived data.

CONCLUSIONS

Administrative data on blood culture use from the PHIS database correlates unpredictably with hospital-derived PICU data. The limitations of administrative billing data should be carefully considered before use for ICU-specific data.

Strategies for Managing Impairing Emotional Outbursts

This Viewpoint discusses the important role pediatricians play in assessment, prevention, and early intervention for children who display impairing emotional outbursts.