An examination of emergency department pediatric psychiatric services

Youth mental health-related presentations at a quaternary centre: Who comes, What are their needs, and Can we meet their needs

Background

Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services.

Objective

To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources.

Methods

We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility.

Results

Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month.

Conclusions

Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs.

Evaluation of an Integrated Psychology Service in a Pediatric Emergency Department and Urgent Care

OBJECTIVES

Children visiting emergency departments (EDs) are disproportionately affected by mental health disorders. Integrated behavioral health models hold promise for improving care among ED patients. We implemented and evaluated a novel behavioral health service integrated psychology trainees in a safety net hospital's pediatric ED and urgent care.

METHODS

Consultations and interventions provided were identified from the service's patient registry. Patients treated by the service were matched based on age, sex, day, and month of presentation to control patients who received a brief assessment by a specialized psychiatric nurse or patients receiving comprehensive management in a psychiatric emergency service. Rates of ED return visits were obtained from local hospital records, and insurance claims were used to identify rates of psychiatric hospitalization and outpatient follow-up care.

RESULTS

The most commonly provided interventions among 71 intervention patients were assistance with connection to follow-up behavioral health treatment (65%), relaxation training (41%), and motivational interviewing (31%). These patients were matched with 142 comparison patients. There was no difference among groups in return rates within 90 days among intervention versus nurse assessment or psychiatric emergency service patients (25% vs 23% vs 13%, P = 0.14). Insurance claims data were available for 115 patients (54%): within 90 days, integrated care patients were less likely to have at least 1 outpatient claim (52% vs 78% vs 84%, P < 0.01), and there was no difference in rates of psychiatric hospital admission (18% vs 20% vs 24%, P = 0.83).

CONCLUSIONS

Although this psychology-led integrated behavioral health service delivered a range of brief psychotherapeutic interventions, its impact on outpatient, inpatient, and emergency care was mixed. This lower follow-up rate among intervention patients may reflect the success of active psychological treatment in the ED, lower acuity among intervention patients, or implications of the study's safety net setting. The authors discuss this model's potential for enhancing mental health care in pediatric EDs.

Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department

Background: Acute agitation in the pediatric emergency department (ED) has the potential to escalate into aggression and result in harm. Rapid and effective management may be warranted. Use of pro re nata (prn) oral immediate-release (IR) quetiapine, haloperidol, loxapine, and chlorpromazine has been observed in the pediatric ED at Surrey Memorial Hospital to manage this condition; however, evidence for oral prn antipsychotic use is limited in the pediatric population. Objectives: The primary objective is to characterize the dose of prn oral IR quetiapine used to manage acute agitation or aggression in a pediatric ED. Secondary objectives include characterizing the dose of prn oral IR haloperidol, loxapine, and chlorpromazine; and describing the 1-hour response rate, admission rate, length of stay (LOS), and adverse drug effects. Method: The medical records of pediatric patients who received at least one prn oral dose of IR quetiapine, haloperidol, loxapine, or chlorpromazine for acute agitation and aggression, without regard to the etiology of symptom presentation, between January 1, 2012 and December 31, 2016, were analyzed retrospectively. Results: Sixty-nine patients met the inclusion criteria. The mean dose of quetiapine was 32 mg/dose (0.54 mg/kg per dose); and the response rate was 53%. The mean haloperidol, loxapine, and chlorpromazine doses were 4 mg (0.07 mg/kg per dose), 13 mg (0.19 mg/kg per dose), and 29 mg/dose (0.53 mg/kg per dose) respectively; and the response rates were 36%, 30%, and 50%, respectively. Between 19% and 60% of patients were admitted, majority to the psychiatry ward. The median LOS in the ED was between 5 and 18 hours for nonadmitted patients. Extrapyramidal side effects (EPS) were reported with first-generation antipsychotics (FGA), but not with quetiapine. Conclusion: Quetiapine appears to be a viable agent for managing acute agitation and aggression in the pediatric ED with low rates of EPS. Further studies are encouraged to compare the effectiveness of quetiapine with FGA. A Clinical Trial Registration number is not applicable for this study.

A Collaborative Behavioral Model for Psychiatric Visits in a Pediatric Emergency Department

OBJECTIVES

Psychiatric pediatric emergency department (PED) visits are associated with extended length of stay (LOS) compared with nonpsychiatric visits. To address delays in definitive care, our PED incorporated a Collaborative Behavioral Model for patients with a psychiatric complaint. We evaluated LOS and 6-month readmission by comparing patients who received a psychiatric consultation through the model with a control group of nonpsychiatric patients. In addition, we assessed the utilization of laboratory tests and imaging and the impact of testing on final patient disposition.

METHODS

A matched-pair retrospective chart review of psychiatric PED visits was conducted for visits from January 1, 2009, to December 31, 2013. Patients who received a psychiatric diagnosis and consultation through the Collaborative Behavioral Model were included. Participants were matched with a control group of similar patients who did not receive a psychiatric diagnosis.

RESULTS

One hundred forty-seven patients met all the inclusion criteria. There was no statistical difference in median LOS for patients who received a psychiatric consultation versus nonpsychiatric visits (204 vs 200 minutes; P = 0.35). The 6-month PED readmission rate for psychiatric visits was significantly less than that in the control group (18% vs 32%; P = 0.003). Of the laboratory and imaging studies performed, 1 abnormal laboratory test (1%) and no imaging studies resulted in a change in patient management.

CONCLUSIONS

Collaborative models, with specialized psychiatric components, can better coordinate the care of mental health visits by providing focused interventions that promote efficient disposition. In addition, laboratory and imaging studies resulted in few changes in management or final disposition.

Emergency Department Utilization for Mental Health in American Indian Children

OBJECTIVES

To examine emergency department (ED) visits for mental health concerns by American Indian children in a multicenter cohort. To analyze demographic and clinical factors, the types of mental health concerns, and repeat mental health visits.

STUDY DESIGN

Cross-sectional study of children 5-18 years old who visited 1 of 6 EDs in the Upper Midwest from June 2011 to May 2012 and self-identified as white or American Indian. Mental health visits were identified by primary diagnosis and reasons for visit and were categorized into diagnostic groups. We explored racial differences in ED visits for mental health, diagnostic groups, and repeat mental health visits. Analysis involved χ(2) tests, Cochran-Mantel-Haenszel tests, and regression models including age, triage, timing, and insurance, and their interactions with race.

RESULTS

We identified 26 004 visits of which 1545 (5.4%) were for a mental health concern. The proportion of visits for mental health differed by race and age. American Indian children had lower odds of a mental health visit for 5-10 year olds (OR, 0.40; 95% CI, 0.26-0.60), but higher odds for 11-17 year olds (OR, 1.62; 95% CI, 1.34-1.95). In the older age group, American Indian children were seen primarily for depression and trauma- and stressor-related disorders, whereas white children were seen primarily for depression and disruptive, impulse control, and conduct disorders. Repeat visits were not different by race.

CONCLUSIONS

Differences were noted in mental health visits between American Indian and white children and were influenced by age. These findings warrant further investigation into care-seeking patterns and treatment for mental health in American Indian children.

Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges

Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.

CARES: improving the care and disposition of psychiatric patients in the pediatric emergency department

OBJECTIVES

Pediatric psychiatric emergencies are a nationwide crisis and have contributed to an increase in behavioral health emergency department (ED) visits. A collaborative response to this crisis was the creation of the Child & Adolescent Rapid Emergency Stabilization (CARES) program. The objective of this study is to determine how the CARES unit influenced length of stay (LOS) and costs for psychiatric patients in the pediatric ED.

METHODS

A retrospective review of ED patients was conducted. Children presenting 1 year before CARES, October 13, 2006, to October 13, 2007 (pre-CARES), were compared with 1 year after, October 15, 2007, to October 15, 2008 (post-CARES). The study population includes all patients presenting to the ED with psychiatric illnesses. The primary outcome is mean LOS in hours. Supplemental analyses of total charges, payments, and costs were performed.

RESULTS

There were 1719 visits before and 1867 visits after CARES, with 1190 and 1273 unique patient visits, respectively. Children in both groups had similar age, gender, and ethnicity. Pre-CARES had a mean LOS of 19.7 hours (SD, 32.6), whereas post-CARES had 10.8 hours (SD, 19.9) (P < 0.0001). Evaluating only unique visits, the difference remained highly significant. Post-CARES, compared with pre-CARES, the average charge per patient decreased by $905 (P < 0.0001), average payment decreased by $111 (P < 0.06), and average total cost decreased by $569 or 38.7% (P < 0.0001). The total cost savings the year after CARES opened was $1,019,168.55.