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

Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature

BACKGROUND

The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families.

OBJECT

This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future.

METHOD

The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed.

RESULT

This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits.

CONCLUSION

Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.

Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County

Background

Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol.

Methods

A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE.

Results

There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter.

Conclusion

Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.

Twitter as a Knowledge Translation Tool to Increase Awareness of the OpenHEARTSMAP Psychosocial Assessment and Management Tool in the Field of Pediatric Emergency Mental Health

Rationale

The increasing prevalence of pediatric mental health presentations in pediatric emergency departments (PED) requires improved integration of evidence-based management strategies. Social media, specifically Twitter, has shown potential to aid in closing the knowledge translation (KT) gap between these evidence-based management strategies and pediatric emergency medicine (PEM) providers.

Aims and objectives

The primary outcome of this study is to evaluate the effectiveness of Twitter as a KT dissemination tool in PEM. The exploratory outcomes were to assess how to effectively implement Twitter in KT, explore ways in which Twitter can maximize the global reach of OpenHEARTSMAP and whether Twitter can lead to increased adoption of OpenHEARTSMAP.

Methods

A one-week prospective promotion on Twitter was conducted to disseminate the OpenHEARTSMAP tool using 15 topic-related hashtags (arm 1, 15 Tweets) versus one post wherein 15 different Twitter users were mentioned in 15 different comments (arm 2, 1 Tweet). A one-week control period immediately prior to posting was employed for comparisons.

Results

During the Twitter week, visits per day to OpenHEARTSMAP increased by 175%; mean time spent on the website increased by 212%; and mean page actions per visit increased by 130%. The greatest increase in visits occurred on the first day of Tweeting. Arm 2 received the greatest engagements. Within arm 1, the category of pediatrics received the most engagements (hashtag #Peds was most popular). Arm 1 received 455 impressions compared to 2071 in arm 2. No new users registered an account on the OpenHEARTSMAP website, which is required to physically use the tool.

Conclusion

Twitter can be an effective KT tool to increase awareness of research, the first step of KT, in the domain of PEM mental health care. Strategies for success include building a robust Twitter following; posting during peak healthcare-related Twitter traffic times; employing hashtags coinciding with current events; and targeting posts by tagging users who need not necessarily be generally well-known opinion leaders.

Social Services and Behavioral Emergencies: Trauma-Informed Evaluation, Diagnosis, and Disposition

The emergency department's role in a psychiatric crisis is to assess for safety, provide crisis interventions, reach a diagnosis, make decisions about disposition and treatment, and provide linkage to the next level of care within the hospital or in the community. The evaluation of children and adolescents involved in the child welfare system brings numerous additional challenges to this already-complex environment, including familial and systemic issues and an almost ubiquitous history of trauma. This article endeavors to increase understanding of child welfare-related issues and provides insight toward using a more trauma-informed and comprehensive approach that incorporates all these factors.

The Impact of Mental Health Services in a Pediatric Emergency Department: The Implications of Having Trained Psychiatric Professionals

OBJECTIVES

This study assessed improvement in the emergency department (ED) length of stay and costs after implementation of an ED program which added board-certified psychiatrists and trained psychiatric social workers to the pediatric ED.

METHODS

A retrospective medical record and administrative data review were conducted for all pediatric psychiatric visits of children aged 5 to 18 years who were seen and discharged from the Greenville Memorial Hospital ED between January 1, 2007, and June 31, 2013. These subjects were diagnosed by the ED physician at the time of the visit using codes ranging from 290.0 to 319.0 based on the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision codes.

RESULTS

The mean (SD) age of children in the postprogram period (14.3 ± 3.1) was younger than during the preprogram period (14.9 ± 3.1) (P < 0.001) with the greatest increase in the 11- to 15-year age group (42% vs 35%, respectively). Patients in the postprogram period were significantly more likely to be discharged to a psychiatric hospital than during the pre-program period (18% vs 9%, respectively). After the initiation of the program, ED length of stay decreased significantly from 14.7 to 12.1 hours (P < 0.001) and costs per visit decreased slightly from US $602 to US $588 (this difference was not statistically significant).

CONCLUSIONS

Although this model of care has significant costs associated with it, the efficiency of care for psychiatric pediatric patients in the ED improved after targeted training of ED staff and provision of these specialized services within the ED.

EMS Activations for School-Aged Children From Public Buildings, Places of Recreation or Sport, and Health Care Facilities in Pennsylvania

OBJECTIVES

To determine the etiology of emergency medical services (EMS) activations in 2011 to public buildings, places of recreation or sport, and health care facilities involving children aged 5 to 18 years in Pennsylvania.

METHODS

Electronic records documenting 2011 EMS activations as provided by the Pennsylvania Department of Health's Bureau of EMS were reviewed. Data elements (demographics, dispatch complaint, mechanism of injury, primary assessment) from patients aged 5 to 18 years involved in an EMS response call originating from either a public building, a place of recreation and sport, or health care facility were analyzed.

RESULTS

A total of 12,289 records were available for analysis. The most common primary assessments from public buildings were traumatic injury, behavioral/psychiatric disorder, syncope/fainting, seizure, and poisoning. The most common primary assessments from places of recreation or sport were traumatic injury, syncope/fainting, altered level of consciousness, respiratory distress, and abdominal pain. The most common primary assessments from health care facilities were behavioral/psychiatric disorder, traumatic injury, abdominal pain, respiratory distress, and syncope/fainting. When examining the mechanism of injury for trauma-related primary assessments, falls were the most common mechanism at all 3 locations, followed by being struck by an object. Of the 1335 serious-incident calls (11% of the total EMS activations meeting inclusion criteria), 61.2% were from public buildings, 14.1% from places of recreation or sport, and 24.7% from health care facilities.

CONCLUSIONS

Our identification of common EMS dispatch complaints, mechanisms of injury, and primary assessments can be used in the education of staff and preparation of facilities for medical emergencies and injuries where children spend time.

Challenges of managing pediatric mental health crises in the emergency department

Children with mental health problems are increasingly being evaluated and treated in pediatric clinical settings. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Pediatric mental health emergencies and special health care needs

Children with mental health problems are increasingly being evaluated and treated by both pediatric primary care and pediatric emergency physicians. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Emergency Department Screening for Adolescent Mental Health Disorders: The Who, What, When, Where, Why and How It Could and Should Be Done

Mental health problems are a significant cause of morbidity and mortality among pediatric populations. Screening for these problems can result in earlier identification and increase treatment and improve outcomes for these children and adolescents. The emergency department (ED) is an ideal site for such screening. Pediatric ED patients are known to be at higher risk for mental health problems. For many, an ED visit is one of the few opportunities to identify and intervene with these children and adolescents. A number of brief, efficient screening instruments have been developed for the ED setting. Screening for mental health problems is both feasible and acceptable to ED patients, parents, and caregivers.

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.

An examination of emergency department pediatric psychiatric services

The purpose of this study was to explore the structure, process, and outcomes of emergency department (ED) psychiatric services that are available to children who present with behavioral health problems. The author designed and employed a 33-item survey for data collection. All nonfederal EDs in one southeastern state (N=68) were solicited to participate. Descriptive analyses including ANOVAs, t tests, and chi-squares summarized sample characteristics and group differences by ED pediatric psychiatric service (EDPPS) arrangement. Thirty-four hospitals participated, sharing similar organizational characteristics with nonresponders except that participating hospitals were significantly more likely to have inpatient psychiatric services. The survey successfully captured data confirming that EDs use a range of strategies to manage children with behavioral health problems, raising concerns about the suitability of such service variation. These results highlight the need for further research that examines the association of EDPPS structure and process with patient and organizational outcomes to inform quality improvements in pediatric behavioral healthcare.

Adolescent depression: views of health care providers in a pediatric emergency department

OBJECTIVE

Pediatric emergency department (PED) providers are strategically positioned to identify adolescents with depression. Our objectives were to describe health care providers' perspectives on adolescent depression and the role of depression screening in the PED.

METHODS

We conducted semistructured interviews with 41 health care providers from an urban, academic PED (including PED attending physicians and trainees, social workers, and psychiatrists). Interviews were audiotaped, transcribed, and entered into the N6 qualitative data analysis software version 6 (QSR International Pty Ltd, Cambridge, Mass) for coding and analysis. A multidisciplinary team used content analysis to identify 2 primary domains: (1) provider attitudes about adolescent depression and (2) factors associated with adolescent depression screening processes in a PED setting.

RESULTS

The PED-based providers demonstrated a clear understanding of the clinical burden of adolescent depression but described complex individual and system-level barriers to addressing the issue. All providers recognized the high prevalence of adolescent depression and its impact on health and described adolescent depression as a moderate-to-large problem that was greatly underrecognized but applied primarily a biomedical model for treatment options. The respondents endorsed computerized screening as a useful approach. Concerns were raised universally regarding the ability of the health care system to respond to screened adolescents found to be depressed.

CONCLUSIONS

The study describes the perspectives of multiple, key stakeholders necessary for a system response to the identification, assessment, and management of adolescent depression in the PED. The PED providers were generally supportive of computerized depression screening in the PED setting but also voiced the need for system-level responses that facilitate access to quality mental health care services for adolescents.

Pediatric emergency medicine physicians' current practices and beliefs regarding mental health screening

BACKGROUND

Only 20% of children with mental health issues are identified and receiving appropriate treatment nationally. The emergency department (ED) may represent a significant opportunity to provide selective pediatric mental health screening to an at-risk population.

OBJECTIVE

To describe the current standard of care and perceived limitations among pediatric emergency medicine (PEM) physicians regarding mental health screening.

METHODS

A 23-question survey on screening practices for pediatric mental illness (PMI) was sent to PEM physician participants identified through the American Academy of Pediatrics Section on Emergency Medicine mailing list.

RESULTS

Of the 576 physicians meeting our inclusion criteria, 384 (67%) surveys were returned. Eighty-six percent of respondents indicated screening for PMI in 10% or less of their eligible patients. Overall, 43% of respondents indicated screening only if the chief complaint was psychiatric in nature. The remaining 217 physicians most commonly screened for depression (83%), suicidality (76%), and substance abuse (67%). Only 9% of physicians stated that they used evidence-based medicine in determining their screening practices. Women physicians (odds ratio, 1.94; 95% confident interval, 1.08-3.47) and those using evidence-based medicine (odds ratio, 3.88; 95% confidence interval, 1.92-7.85) were more likely to conduct screening. Significant limitations to screening identified by respondents include the following: time limitations (93%), absence of a validated screening tool (62%), limited resources (46%), and lack of training (44%). Eighty-eight percent of physicians believe that a validated and standardized screening tool would improve their ability to identify PMI.

CONCLUSIONS

Routine PMI screening is conducted infrequently by most PEM physicians. Improved physician education/training and the development of a validated ED-specific mental health screening tool would assist PEM physicians in the early detection of PMI.

Short Term Involuntary Psychiatric Examination of Children in Florida

This study describes the use of emergency mental health services by children over a 4-year period. Analysis of a statewide database revealed 51,861 or 15% of all involuntary examinations were conducted on children. These youth were on average a little over 14 years of age and law enforcement officials initiated the majority of examinations. The majority of examinations were initiated due to the children demonstrating harmful behaviors to themselves or others. One-fifth of the children (21%) experienced more than one examination over the 4-year period. Areas of future research on this topic are discussed. The implications of the nature of examinations and patterns of repeated examinations are discussed.

Screening for adolescent depression in a pediatric emergency department

OBJECTIVES

To describe the prevalence of depressive symptoms in adolescents presenting to the emergency department (ED) and to describe their demographics and outcomes compared with adolescents endorsing low levels of depressive symptoms.

METHODS

The Beck Depression Inventory-2nd edition (BDI-II) was used to screen all patients 13-19 years of age who presented to the ED during the period of study. The BDI-II is a 21-item self-report instrument used to measure the presence and severity of depressive symptoms in adolescents and adults. Demographics and clinical outcomes of screening-program participants were abstracted by chart review. Patients were categorized into one of four severity categories (minimal, mild, moderate, or severe) and one of three presenting complaint categories (medical, trauma, mental health).

RESULTS

Four hundred eighty-seven patients were approached, and 351(72%) completed the screening protocol. Participants endorsed minimal (n = 192, 55%), mild (n = 52, 15%), moderate (n = 41, 11%), or severe depressive symptoms (n = 66, 19%). Those with moderate or severe depressive symptoms were more likely to be hospitalized. Of patients completing the BDI-II, 72% with psychiatric, 12% with traumatic, and 19% with medical chief complaints endorsed either moderate or severe depressive symptoms.

CONCLUSIONS

Depressive symptoms are prevalent in this screening sample, regardless of presenting complaint. A substantial proportion of patients with nonpsychiatric chief complaints endorsed moderate or severe depressive symptoms. A screening program might allow earlier identification and referral of patients at risk for depression.