Profile of a comprehensive psychiatric emergency program in a New York City municipal hospital

Trends and Geographic Availability of Emergency Psychiatric Walk-In and Crisis Services in the United States

OBJECTIVE

Serious mental illness places a considerable burden on the mental health service system in the United States. To date, no research has examined the availability of psychiatric emergency walk-in and crisis services. The goal of this study was to examine temporal trends, geographic variation, and characteristics of psychiatric facilities that provide emergency psychiatric walk-in and crisis services across the United States.

METHODS

The authors used cross-sectional, annually collected data covering the 2014-2018 period from the National Mental Health Services Survey (N-MHSS), a representative survey of both public and private mental health treatment facilities in the United States.

RESULTS

Overall, 42.6% of all U.S. mental health facilities did not offer any mental health crisis services between 2014 and 2018. A third of all facilities (33.5%) offered emergency psychiatric walk-in services, and just under one-half (48.3%) provided crisis services. When examining population-adjusted estimates, the authors noted a 15.8% (1.52-1.28 per 100,000 U.S. adults) and 7.5% (2.01-1.86 per 100,000 U.S. adults) decrease in walk-in and crisis services, respectively, from 2014 to 2018. Large geographic variation in service availability was also observed.

CONCLUSION

A large proportion of psychiatric facilities in the United States do not provide psychiatric walk-in or crisis services. Availability of these services either has stayed flat or is declining. Disparities, particularly around U.S. borders and coasts, suggest policy efforts would be valuable for ensuring equitable service availability.

Treatment of Patients with Mental Illness Amid A Global COVID-19 Pandemic

A newly discovered coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing pandemic of coronavirus disease 2019 (COVID-19), which is not only physically challenging but also has many subtle and overt mental impacts. The concern of being infected, lack of antiviral agents, preventive strategies of social distancing, and home isolation have created unrest in the society. The way of reacting to emergencies varies from individual to individual, and that this variability lies in our unique personality traits. The COVID-19 pandemic is testing the mental stability of all of us, and hence it is crucial to recognize the vulnerable population and support them to prevent or minimize the catastrophe like post-traumatic stress disorder (PTSD), emotional trauma, and suicides. In this context, the role of psychiatrists, psychotherapists, and other mental healthcare providers is indispensable.

Systematic review of interventions to improve constant observation on adult inpatient psychiatric wards

Constant observation is frequently conducted on inpatient psychiatric units to manage patients at risk of harming themselves or others. Despite its widespread use, there is little evidence of the efficacy of the practice or of its impact on patients and nursing staff. Unnecessary use of this practice can be restrictive and distressing for all involved and can cause considerable strain on healthcare resources. We sought to review interventions aiming to improve the quality and safety of constant observation or to reduce unnecessary use of this restrictive practice on adult inpatient psychiatric wards. A systematic search conducted in December 2018 using PubMed, PsycINFO, CINAHL, EMBASE and Google Scholar identified 24 studies with interventions related to constant observation. Only 16 studies evaluated a total of 13 interventions. The most common intervention components were changes to team, education and training for staff, changes to record keeping and assessment, and involving patients in care. A range of outcome measures were used to evaluate interventions. Over half of the interventions showed some positive impact on constant observation. One study recorded patient feedback. All interventions were targeted towards mental health nurses. Overall, there is no consensus on how best to improve the safety and quality of constant observations or reduce its unnecessary use. Studies vary widely in design, intervention and outcome measures. Existing research does however suggest that teamwork interventions can improve the patient experience of constant observation and safely reduce their degree and frequency. Priorities for future research on constant observations are highlighted.

Factors associated with prolonged length of stay in the psychiatric emergency service

OBJECTIVE

Dedicated regional psychiatric emergency services (PES) were proposed as a better care model for psychiatric emergencies and a possible solution to boarding of psychiatric patients in the emergency department. However, there are limited data on factors associated with prolonged length of stay (LOS) in the PES. The objective of this study was finding factors associated with prolonged LOS in the PES and moving towards a solution to this problem.

METHODS

The study sample comprised 200 PES visits randomly chosen from January 2011 to December 2015 in a psychiatric hospital in Taiwan. Relevant data were collected comprehensively through the health information system and by reviewing medical records. The primary outcome was LOS longer than 24 hours while LOS longer than 48 hours was used as the secondary outcome.

RESULTS

Mean LOS was 17.6±23.2 hours, with 53 (26.5%) visits lasting more than 24 hours and 15 (7.5%) visits lasting more than 48 hours. After adjusting for related confounders, LOS longer than 24 hours was associated with use of restraints in the PES (adjusted odds ratio (aOR) = 3.13, 95% CI = 1.59-6.15) and history of illicit substance use (aOR = 2.46, 95% CI = 1.11-5.44). LOS longer than 48 hours was associated with use of restraints in the PES (aOR = 4.11, 95% CI = 1.2-14.14), history of illicit substance use (aOR = 6.16, 95% CI = 1.37-27.62) and first time visit to the hospital (aOR = 8.54, 95% CI = 2.03-35.96). Neither outcome was associated with transfer to an inpatient unit.

CONCLUSION

Prolonged LOS was common in the study sample. Discharged patients had an equally high rate of prolonged LOS as admitted patients. Therefore measures should be taken to facilitate timely discharge. Use of restraints and history of illicit substance use were common among patients with prolonged LOS.

Emergency psychiatric care for children and adolescents: a literature review

OBJECTIVES

Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions "which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized."

METHODS

We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems.

RESULTS

The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents.

CONCLUSIONS

Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings.

Pediatric mental health concerns in the emergency department: caregiver and youth perceptions and expectations

OBJECTIVES

The main purpose of this research was to identify the perceived mental health (MH) concerns of caregivers and youths who present to the emergency department (ED) for MH services. The concordance between caregiver and youth perceptions and clinician ratings of MH concerns were evaluated. Expectations for the visit and perceived stressors that triggered the event are described.

METHODS

This study consisted of 241 youths accompanied by caregivers presenting to the ED for MH concerns requiring crisis intervention services. The Caregiver Perception Survey and Youth Perception Survey were completed. These surveys were designed to identify the caregivers' and youths' main concerns and perceived stressors, as well as their expectations in coming to the pediatric ED. A chi analysis was conducted to determine the percentage of agreement of reported MH concerns between groups (youth, caregiver, and clinician), and kappa statistics are reported.

RESULTS

Caregivers' and youths' top 5 concerns were suicide ideation, depression or mood, suicidal attempt, anxiety, and self-injury. The top 3 stresses identified by both youths and their caregivers were school, issues with parents, and problems with friends/peers. The top 3 expectations that were noted by caregivers were help/guidance for child, assessment/ evaluation/diagnosis, and health care professional resources. Concordance rates between caregivers and youths for the top 5 concerns ranged from 39.4% to 80.6%. Concordance rates between clinician rating of concerns (as requiring some or immediate action) and caregiver concerns ranged from 18.4% to 45.2%. Concordance rates between clinician and youth ranged from 11.1% to 59.4%.

CONCLUSIONS

The top 5 caregivers and youths' main concerns for coming to the ED were similar. However, concordance between perceived concern and clinician assessment is low. Caregivers' expectations for coming to the ED highlight their lack of knowledge of referral procedures and MH services.

Establishing best practice in pediatric emergency mental health: a prospective study examining clinical characteristics

OBJECTIVES

The objectives of this prospective study were to determine the demographic and clinical characteristics of children and youth presenting to the emergency department (ED) for mental health concerns through the use of a valid standardized assessment protocol.

METHODS

Children and adolescents, 8 to 17 years, who presented to an ED-based crisis intervention program during fiscal years 2005 to 2006, completed self-report measures of depression, anxiety, and behavior. Clinicians completed the childhood acuity of psychiatric illness based on their assessment.

RESULTS

The clinician ratings indicated that 93.1% of the sample had at least 1 risk behavior or clinical symptom in the moderate/severe range. Admittance rate for the sample was 17.9% (low-risk admissions, 5.8%; high-risk deflections, 9%). Significant differences were found in presentations by sex and age as follows: (1) female youths (12-17 years) were more likely than male youth to report clinically significant depressive symptoms and to present with suicidal ideation/gesture and self-injury. (2) Male youths (12-17 years) were more likely to present with aggression to people/objects than female youth. (3) Male children younger than 12 years were more likely to present with high activity level than female children. Self-report measures (depression, anxiety, and behavior) corelated with corresponding clinician ratings.

CONCLUSIONS

This research, through the use of a multi-informant standardized assessment protocol, presents a comprehensive study of children and youth presenting to the ED with mental health issues. Identifying the clinical characteristics of this population is an important first step toward establishing best practice within an ED.

Is psychiatric emergency service (PES) use increasing over time?

BACKGROUND

Several recent studies have reported a significant increase in medical emergency department (ED) use for reasons of mental health. The diagnostic profile of these patients however differs from that usually described for patients visiting the psychiatric emergency service (PES). Few studies have specifically focused upon long-term PES utilization rates. Those that do typically present data from the early 80s, suggesting that deinstitutionalization may be an important contributing factor to the increases found. The aim of this study was to assess PES use using a more recent time frame and, the effects of non-specific factors, such as population growth, on this use.

METHODS

Visits per year at several different types of PESs were obtained; (a) for an 11-year period at a general hospital PES while the surrounding population remained stable, (b) at that same PES while the catchment area population doubled over a period of a few years, (c) for an 11-year period at two PESs without catchment areas while the surrounding population increased and (d-) for a 12-year period at a PES in a mental health facility while the surrounding population increased. Moderately conservative criteria were used to define either a trend or, a significant increase in utilization rates.

RESULTS

Each site had an inherent, 7 to 15% yearly variability in the number of PES visits. Over time however, only those where the surrounding population increased (either by an increase in the catchment area size or a regional increase in the population census) showed a trend or, a significant increase in utilization rates. These increases however were modest and of the order of 12 to 19%.

CONCLUSION

Long observation periods are required in order to detect stable changes in PES utilization rates over time. As such, population growth may be but one of several factors underlying these increases. Organizational changes in mental health care delivery in the vicinity of the services that showed an increase could also have contributed. These latter would simply have redistributed (to the PES) the pre existing pool of mental health care patients, resulting in an increase that is more apparent than real.

Child and adolescent psychiatric emergencies in nonsuicide-specific samples: the state of the research literature

OBJECTIVE

Since the 1980s, there has been an increase in the frequency with which children and adolescents with psychiatric symptoms present to emergency departments (ED). Recent trend data from the National Hospital Ambulatory Medical Care Survey database suggest that the increase in ED use for mental health concerns is not driven by a rise in the frequency of medically serious suicide attempts but, rather, nonurgent diagnoses. The current paper is a systematic review of the existing research literature on child and adolescent psychiatric emergencies among nonsuicidal samples to assess the type and quality of the data reported. This is a first step in developing a profile of which children, in the absence of medically serious suicide attempt, seek psychiatric care in EDs.

METHODS

Literature searches were conducted through PsycINFO, MEDLINE, and PubMed databases for the years 1990 through 2004. Twelve studies were identified as meeting inclusion criteria and were reviewed for general study information (ie, bibliography); quality indicators; study characteristics (ie, data source, location of study, method of subject recruitment, and study inclusion/exclusion criteria); subject characteristics, and outcome measures and results (specific outcome assessed, types of data analyses).

RESULTS

Most of the studies were cross-sectional, retrospective chart reviews, with one data source. Only one study reported on all variables of interest, and there was no consistency in data collection or reporting across studies.

CONCLUSIONS

Although there has been a documented increase in children and adolescents seeking care for psychiatric emergencies in EDs, a clear and basic understanding of who these patients are cannot be determined from existing published research reports. Significant inconsistencies in data collection and reporting make recommendations for treatment planning and service delivery challenging. A research agenda in the field of child and adolescent psychiatric emergencies is proposed.

A profile of mental health crisis response in a rural setting

Systems of crisis intervention are frequently difficult to operationalize; they are often described as crisis components rather than systems, fail to differentiate levels of crisis acuity, provide very limited fundamental utilization data, and are almost exclusively implemented in urban areas. A system of rural crisis intervention differentiating levels of acuity and fundamental utilization information was profiled. Implications for clinicians and administrators are presented. This system of crisis intervention was highly effective in reducing inpatient utilization with the help of crisis residential beds and partial hospitalization. Mobile response was infrequently used in this setting. Age and gender were important variables in mental health emergency situations. Use of acute crisis level services was rarely more than once. More systematic descriptions of crisis systems of care were encouraged.

Mental health visits in a pediatric emergency department and their relationship to the school calendar

OBJECTIVES

Over the past decade, there has been a significant increase in the rate at which children and adolescents present to emergency departments (EDs) with mental health complaints. The goal of the current study was to assess the rate of ED usage for children and adolescents and to determine if there was an association between mental health emergencies and the school year.

METHODS

Retrospective chart review of 719 psychiatric consultations to an urban ED affiliated with an academic medical center. Records of consultations from April 2001 to March 2002 were reviewed and abstracted for variables such as age, sex, time and date of presentation, and psychosocial factors.

RESULTS

Chi2 analyses reveal significant associations between presentation to the ED for a psychiatric complaint and time of day, day of week, and month of year. One-way analyses of variance also demonstrated mean differences in presentations for day of week and month of year.

CONCLUSIONS

The current study supports previous research findings of an association between the school year and child and adolescent mental health emergencies. In the current study, the school year appears to exacerbate childhood problems, as there is a greater frequency of psychiatric emergencies while children are in school. Implications for ED program development and school-based mental health service delivery are reviewed.

Emergency medicine training programs' educational requirements in the management of psychiatric emergencies: current perspective

OBJECTIVE

The purpose of this study was to determine the extent of training in clinical psychiatry that is provided and/or required by emergency medicine (EM) residency training programs and pediatric emergency medicine (PEM) subspecialty residency training programs.

DESIGN/METHODS

A questionnaire was mailed to 114 EM residency directors and to all 50 PEM fellowship directors. Each director was asked to indicate the amount of psychiatric training that was required of residents or fellows in his or her program. Details concerning the exact structure of psychiatric training were solicited from those offering such training.

RESULTS

There was a 76% response rate (n = 88) among EM programs, and 76% (n = 59) of the respondents reported no formal training in the management of acute psychiatric emergencies. Only 14% (12 programs) provide a 1-month rotation in psychiatry. Of the 3-year programs, 14% (n = 11) offer 2-week psychiatric electives, and 9% (n = 8) offer some training. There was a 72% response rate among the PEM training programs. Only one of the 36 respondents provided a required 1-month rotation in psychiatry. Six programs stated the availability of a 1-month elective in psychiatry. Two programs reported 2 to 3 hours per year of core lecture time dedicated to psychiatric emergencies.

CONCLUSIONS

Standardized psychiatric training is not required of most trainees in EM and PEM. Few (24%) training programs provide formal psychiatric training for their EM residents, and even fewer (< 3%) provide such training for their PEM fellows.

Treatment of pediatric and adolescent mental health emergencies in the United States: current practices, models, barriers, and potential solutions

Mental illness significantly impairs the lives of 10% of all children and adolescents in the United States (National Institute of Mental Health. Brief Notes on the Mental Health of Children and Adolescents. Bethesda, MD: National Institute of Mental Health, 1999). Of the myriad mental health problems afflicting children, an alarming number are known to have grim outcomes. Some illnesses continue into adulthood, while others may culminate in death during adolescence. Despite the serious consequences of children's mental health problems, early treatment can improve or control these conditions. Even with this knowledge, seemingly little effort is geared toward removing barriers to treatment for these diseases that plague our children. As a part of its five-year plan, Emergency Medical Services for Children (EMSC) has collaborated with the National Association of EMS Physicians (NAEMSP) to examine childhood and adolescent mental health emergencies--particularly their presentation and management within the emergency medical services system. This document presents a critical review of current practices and models for treatment of children and adolescents that includes identification of barriers to mental health treatment and recommendations for their resolution.