A Quiet Crisis: Pediatric Patients Waiting for Inpatient Psychiatric Care

Factors Associated With Discharge Against Medical Advice in US Adolescents Hospitalized for Suicidal Ideation or Suicide Attempt

OBJECTIVE

Little is known about factors associated with discharge against medical advice (DAMA) in adolescent acute care hospitalization for suicidal ideation (SI) and suicide attempt (SA). Our study seeks to determine whether certain socioeconomic factors or hospital characteristics are associated with DAMA in this population.

METHOD

This retrospective cross-sectional study used data from the National Inpatient Sample from the 2015 fourth quarter to 2019. We included children 10 to 19 years of age hospitalized with a primary or secondary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of SI or SA. Exposures were patient socio-demographics and hospital characteristics. The outcome was DAMA. Logistic regression generated odds ratios (ORs) with 95% CIs to measure the association between each patient and hospital characteristics and DAMA.

RESULTS

Of 476,755 hospitalizations meeting inclusion criteria, 3,825 (0.8%) were DAMA. After adjusting for socio-demographics and hospital characteristics, predictive factors for DAMA were age 16 to 19 years (OR = 1.41; CI = 1.08-1.82), self-pay status (OR = 1.43; CI = 1.12-1.83), hospital region South and West (OR = 1.55; CI = 1.10-2.20 and OR = 1.79; CI = 1.26-2.54, respectively), and urban non-teaching status of the hospital (OR = 1.90; CI = 1.42-2.55). Hispanic patients were less likely to be DAMA (OR = 0.66; CI = 0.51-0.85).

PLAIN LANGUAGE SUMMARY

This study utilized retrospective data from the National Inpatient Sample (2015 to 2019) to determine predictive factors for discharge against medical advice (DAMA) for youth, aged 10 to 19 years old, hospitalized for suicidal ideation or suicide attempt. Of 476,755 hospitalizations for suicidality, 3,825 (0.8%) were discharged against medical advice. Correlates of discharge against medical advice included age 16 to 19 years, self-pay status, admission to an urban non-teaching hospital, or a hospital located in the South or West Regions of the United States. Hispanic patients were less likely to be discharged against medical advice with no other racial/ ethnic differences observed.

CONCLUSION

Variations in DAMA probabilities by age, insurance status, hospital teaching status, and hospital regions suggest a need for a better understanding of this uncommon outcome.

A Review of Telepsychiatry for Pediatric Patients in the Emergency Setting

PURPOSE OF REVIEW

The purpose of this review is to summarize factors contributing to the current state of pediatric mental health access in ED settings and synthesize the existing literature on the use of telepsychiatry to extend access to care, with particular focus on feasibility and sustainability.

RECENT FINDINGS

Children are presenting to emergency departments (EDs) with mental health concerns at an increasing rate, while ED capacity to treat psychiatric needs in children remains insufficient. This growing problem is compounded by decreased access to outpatient care and inpatient psychiatric beds, resulting in exorbitantly long waiting times, or "boarding," of children in crisis. Telepsychiatry has emerged as a strategy to decrease boarding of pediatric patients in ED settings by utilizing remote psychiatric professionals to provide consultation and assessment. Telepsychiatry in ED settings is an effective strategy to increase access to care and decrease length of stay for pediatric patients.

Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital

INTRODUCTION

An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years.

METHODS

A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes.

RESULTS

Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %).

DISCUSSION

Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Factors associated with a change in disposition for mental health patients boarding in an urban Paediatric emergency department

AIM

Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome.

METHODS

A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups.

RESULTS

Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%).

CONCLUSION

These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services.

Sensory-Friendly Emergency Department Visit for Patients with Autism Spectrum Disorder—A Scoping Review

Our goal was to develop non-pharmacologic strategies for addressing sensory challenges that patients with autism spectrum disorder (ASD) face in emergency departments (EDs). Search of five databases for articles written in English and published since 1980 returned 816 citations, of which 28 papers were selected for review. All studies were published in the last nine years, with 92.85% (n = 26) conducted in North America. We developed 26 consolidated strategies, encompassing five major domains, including guiding principles, care processes, people (behavior of staff members), objects, and places (facility design). Sensory-friendly care in ED requires an integrative approach and its success depends on guiding principles that tie various aspects of care and distinguishes ASD care from non-ASD care.

Suicide and Self-Harm in Children and Adolescents Admitted to PICUs in the United States

OBJECTIVES

To characterize the epidemiology of children and adolescents admitted for deliberate self-harm to PICUs in the United States by examining patient demographics, diagnoses, modes of self-harm, and outcomes.

DESIGN

Descriptive analysis of a large, multicenter, quality-controlled database.

SETTING

The 137 PICUs participating in the Virtual Pediatric Systems database during the study period.

PATIENTS

Children between 6 and 18 years old admitted to a participating PICU from January 1, 2009, to December 31, 2017, with a diagnosis involving deliberate self-harm or a suicide attempt.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 9,197 admissions for self-harm, females accounted for 6,740 (73.3%), whereas males incurred 174 of the 284 deaths (61.3%). Admissions for self-harm doubled over the study period (0.56% in 2009 vs 1.13% in 2017), with an increase observed across every age group. After PICU care, most patients were transferred to a general care floor (51.1%) or to a psychiatric rehabilitation facility (31.8%). Intentional drug ingestion (84%) was the most common mode of self-harm but was associated with less than 1% of the fatalities. Asphyxia/hanging or firearms were a factor in 411 (4.5%) and 106 (1.2%) of the admissions but were associated with 117 (28.5%) and 55 (51.9%) of the deaths, respectively.

CONCLUSIONS

PICU admissions due to self-harm increased for all age groups during the study period. Females accounted for most of these admissions, whereas males accrued most of the in-hospital deaths. Intentional drug ingestion was the most common mode of self-harm and was rarely fatal, whereas asphyxia and firearms were the mechanisms associated with the highest mortality.

The Role of the Child and Adolescent Psychiatrist in Systems of Care

To effectively fulfill various roles in systems of care, a child and adolescent psychiatrist must first define "system of care" and become familiar with the child-serving systems that make up the overarching system of care. They should know what roles are currently being fulfilled by child and adolescent psychiatrists, recognize the challenges they may face while fulfilling these roles, and use this knowledge to become catalysts for system improvements. This article discusses these points in greater detail.

Utilizing a Behavioral Health Bundle to Improve Patient and Clinician Safety for Hospitalized Children

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Due to limited psychiatric hospital availability, increasing numbers of pediatric patients with behavioral health (BH) needs are hospitalized in medical units in the US Patients and staff are at increased risk for safety events like self-harm or aggression. Our study aimed to decrease safety events by 25% over a year among hospitalized children with BH diagnoses by implementing an intervention bundle.

Acute psychiatric care for pediatric patients

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Telepsychiatric Evaluation and Consultation in Emergency Care Settings

Telepsychiatric care in the emergency setting is a viable and accessible modality that helps address the needs of patients, families, and communities. An expanding literature base for telepsychiatry in multiple clinical settings has shown benefits, including increased access to care, equal efficacy to face-to-face encounters, cost efficiency, decreased wait-times, decreased unnecessary psychiatric hospitalizations, and high levels of patient satisfaction. The evidence base for emergency telepsychiatry is growing for pediatric populations. Increased use of the modality is part of the solution to address high demand for pediatric psychiatric expertise in emergency rooms and to help bridge service gaps in parts of the country.