Exploring differences in the clinical management of pediatric mental health in the emergency department

Psychotropic Medication Administration in Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES

Visits by youth to the emergency department (ED) with mental and behavioral health (MBH) conditions are increasing, yet use of psychotropic medications during visits has not been well described. We aimed to assess changes in psychotropic medication use over time, overall and by medication category, and variation in medication administration across hospitals.

METHODS

We conducted a retrospective cross-sectional study of ED encounters by youth aged 3-21 with MBH diagnoses using the Pediatric Health Information System, 2013-2022. Medication categories included psychotherapeutics, stimulants, anticonvulsants, antihistamines, antihypertensives, and other. We constructed regression models to examine trends in use over time, overall and by medication category, and variation by hospital.

RESULTS

Of 670 911 ED encounters by youth with a MBH diagnosis, 12.3% had psychotropic medication administered. The percentage of MBH encounters with psychotropic medication administered increased from 7.9% to16.3% from 2013-2022 with the odds of administration increasing each year (odds ratio, 1.09; 95% confidence interval, 1.05-1.13). Use of all medication categories except for antianxiety medications increased significantly over time. The proportion of encounters with psychotropic medication administered ranged from 4.2%-23.1% across hospitals (P < .001). The number of psychotropic medications administered significantly varied from 81 to 792 medications per 1000 MBH encounters across hospitals (P < .001).

CONCLUSIONS

Administration of psychotropic medications during MBH ED encounters is increasing over time and varies across hospitals. Inconsistent practice patterns indicate that opportunities are available to standardize ED management of pediatric MBH conditions to enhance quality of care.

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.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients

OBJECTIVES

Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED.

METHODS

Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences.

RESULTS

Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition.

CONCLUSIONS

ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

Review: Impact of urgent youth outpatient mental health care on patient and health system outcomes - a scoping review

BACKGROUND

Young people often face barriers to psychiatric care and are increasingly seeking crisis services for mental health issues through the emergency department (ED). Urgent psychiatric care models provide youth in crisis with rapid access to time-limited mental health care on an outpatient basis. This scoping review aims to evaluate the impact of such urgent psychiatric services for youth aged 13-25 on patient and health system outcomes.

METHODS

We conducted a literature search on PubMed, EMBASE, MEDLINE, PsycINFO, and the Cochrane Database of Systematic Reviews for studies published from inception to November 20, 2020. We included studies that described outpatient psychiatric services designed for youth aged 13 to 25, took place in a clinical setting, and offered any combination of assessment, treatment, and referral. We excluded studies describing suicide intervention programmes.

RESULTS

Our search yielded six studies, four of which were descriptive studies and two of which were randomized controlled trials. Most studies found that access to urgent psychiatric care for youth was associated with reduced ED volumes, fewer health system costs, and fewer hospitalizations. None of the studies presented evidence that urgent psychiatric services are associated with improved patient symptomatology or functioning.

CONCLUSIONS

The results of this scoping review highlight the scarcity of robust evidence evaluating the effectiveness of urgent care for youth mental health. Further experimental studies and a set of standardized quality measures for evaluating these services are needed to bridge this critical gap in mental health care for youth in crisis.

Do adolescents and young adults accessing the Emergency Room with substance use receive poor therapeutic indications at discharge? An observational retrospective study

PURPOSE

Emergency rooms (ERs) are usually the first point of contact with mental health services for adolescents with Substance Use Disorders (SUDs). However, only a minority of them receives proper treatment and follow-up indications, increasing the risk of relapses and poor prognosis. In this perspective, we sought to characterize and compare socio-demographic and clinical characteristics of adolescents with vs without SUDs accessing the ER, assessing potential differences in terms of discharge instructions.

METHODS

A sample of 557 ER accesses of patients aged 15-25 years old in need of a psychiatric evaluation or with a psychiatric diagnosis at discharge was retrospectively analyzed. Patients were divided in two subgroups according to the presence of SUDs.

RESULTS

About 32.1% of patients had SUDs when accessing the ER. Among these, 62% were unknown to any psychiatric services and 57% were at their psychiatric onset. Nevertheless, considering discharge instructions, patients with current substance use received less therapeutic indication or were less frequently referred to psychiatric facilities, than those without substance use (57.8% vs 42.2%, P = .002).

CONCLUSIONS

Substance abuse is strongly linked to psychopathology and ER accesses in young patients. However, we observed a large rate of SUDs patients unknown by any specialized mental health service, who received poor therapeutic and follow-up instructions at discharge. Improving communication between ER operators and young patients with SUDs could longitudinally reduce the risk of addiction and related disability, morbidity and mortality.

Trends in Visits and Costs for Mental Health Emergencies in a Pediatric Emergency Department, 2010-2016

OBJECTIVE

Analyze trends in visit numbers, length of stay (LOS), and costs of pediatric mental health emergency department (ED) visits over time.

METHODS

We conducted a cross-sectional, time-series analysis from 2010 to 2016 of mental health visits, identified by billing diagnosis codes, among children 5 to 18years old in a tertiary pediatric ED. We used Poisson regression to analyze trends in rates of mental health visits, patient-hours, and visits with LOS ≥ 24hours. We used time-series analysis to trend median costs per visit.

RESULTS

From 2010 to 2016, there were 197,982 ED visits and 13,367 (6.7%) mental health visits. Mental health visits increased by 45% (from 1462 to 2119), compared to a 13% increase in non-mental health visits. The rate of mental health visits increased from 5.6 to 7.1 per 100 ED visits and increased 5.5% annually, compared to -0.4% annually for non-mental health visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.05-1.07). Mental health patient-hours increased 186%, compared to an 18% increase in non-mental health patient-hours. The rate of mental health visits with LOS ≥ 24hours increased from 4.3 to 18.8 per 100 mental health visits and increased 22% annually (IRR, 1.22; 95% CI, 1.19-1.26). Median costs per visit increased by $38 per quarter (95% CI, $28-$48).

CONCLUSIONS

Rates of mental health visits, patient-hours, visits with LOS ≥ 24hours, and visit costs are increasing over time. Additional hospital and community resources are needed to address rising ED utilization for mental illness in children.

Factors associated with boarding and length of stay for pediatric mental health emergency visits

OBJECTIVE

To determine demographic and clinical risk factors associated with boarding (length of stay ≥24 h) for pediatric mental health emergency department (ED) visits.

METHODS

This is a retrospective cross-sectional analysis of mental health visits identified by diagnosis codes for children 5-18 years old presenting to a tertiary pediatric ED in 2016. We performed multivariate logistic regression to identify demographic and clinical factors associated with boarding.

RESULTS

There were 1746 mental health visits and 386 (22%) visits had length of stay ≥24 h. In the multivariate logistic regression model, factors associated with boarding included: private insurance (OR 1.59, 95% CI 1.15, 2.19) and having both private and public insurance (OR 1.68, 95% CI 1.16, 2.43) relative to public insurance; presentation during a school month (OR 2.17, 95% CI 1.30, 3.63); physical or chemical restraint use (OR 4.80, 95% CI 2.61, 8.84); comorbid autism or developmental delay (OR 1.82, 95% CI 1.35, 2.46); prior psychiatric hospitalization (OR 2.55, 95% CI 1.93, 3.36); and reasons for presentation of agitation, aggression, or homicidal ideation (OR 2.76, 95% CI 1.40, 5.45), depression, self-injury, or suicidal ideation (OR 2.79, 95% CI 1.45, 5.40), and bipolar, mania, or psychosis (OR 5.78, 95% CI 2.36, 14.09) relative to anxiety.

CONCLUSIONS

Insurance status, presentation month, restraint use, autism or developmental delay comorbidity, prior psychiatric hospitalization, and reason for presentation are associated with pediatric mental health ED boarding. Resources should be directed to improve the mental health care system for children with identified risk factors for boarding.

Reliability of HEARTSMAP as a Tool for Evaluating Psychosocial Assessment Documentation Practices in Emergency Departments for Pediatric Mental Health Complaints

OBJECTIVES

The goal of this study was to assess the reliability of HEARTSMAP as a standardized tool for evaluating the quality of psychosocial assessment documentation of pediatric mental health (MH) presentations to the emergency department (ED). In addition, we report on current documentation practices.

METHODS

We conducted a retrospective cross-sectional study of pediatric (up to age 17) MH-related visits to four EDs between April 1, 2013, and March 31, 2014. The primary outcome was the inter-rater agreement when evaluating the completeness of pediatric emergency psychosocial assessments using the HEARTSMAP tool. The secondary outcome was to describe the adequacy of documentation of emergency pediatric MH assessments, using HEARTSMAP as a guide for a complete assessment.

RESULTS

A total of 400 medical records (100 from each site) were reviewed. We observed near-perfect inter-rater agreement (κ = 0.99-1.00) regarding the presence of documentation and good-to-perfect agreement (κ = 0.71-1.00) regarding whether sufficient information was documented to score a severity level for every component of an emergency psychosocial assessment. Inter-rater agreement regarding whether referrals or resources were documented for identified needs was observed to be good to very good (κ = 0.62-0.98). Current psychosocial documentation practices were found to be inconsistent with significant variability in the presence of documentation pertaining to HEARTSMAP sections between medical centers and initial clinician assessor and whether specialized MH services were involved prior to discharge.

CONCLUSIONS

The HEARTSMAP tool can be reliably used to assess pediatric psychosocial assessment documentation across a diverse range of EDs. Current documentation practices are variable and often inadequate, and the HEARTSMAP tool can aid in quality improvement initiatives to standardize and optimize care for the growing burden of pediatric mental illness.

A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders

BACKGROUND

Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders.

METHODS

Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel.

RESULTS

Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications.

CONCLUSIONS

The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.

Evaluating mental health service use during and after emergency department visits in a multisite cohort of Canadian children and youth

Objectives

The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed.

Methods

A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher’s exact test to compare sites.

Results

The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed.

Conclusions

Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.

Barriers and Facilitators to Implementing the HEADS-ED: A Rapid Screening Tool for Pediatric Patients in Emergency Departments

OBJECTIVES

This study sought to identify barriers and facilitators to the implementation of the HEADS-ED, a screening tool appropriate for use in the emergency department (ED) that facilitates standardized assessments, discharge planning, charting, and linking pediatric mental health patients to appropriate community resources.

METHODS

A qualitative theory-based design was used to identify barriers and facilitators to implementing the HEADS-ED tool. Focus groups were conducted with participants recruited from 6 different ED settings across 2 provinces (Ontario and Nova Scotia). The Theoretical Domains Framework was used as a conceptual framework to guide data collection and to identify themes from focus group discussions.

RESULTS

The following themes spanning 12 domains were identified as reflective of participants' beliefs about the barriers and facilitators to implementing the HEADS-ED tool: knowledge, skills, beliefs about capabilities, social professional role and identity, optimism, beliefs about consequences, reinforcement, environmental context and resources, social influences, emotion, behavioral regulation and memory, and attention and decision process.

CONCLUSIONS

The HEADS-ED has the potential to address the need for better discharge planning, complete charting, and standardized assessments for the increasing population of pediatric mental health patients who present to EDs. This study has identified potential barriers and facilitators, which should be considered when developing an implementation plan for adopting the HEADS-ED tool into practice within EDs.

Determinants of Pediatric Psychiatry Length of Stay in 2 Urban Emergency Departments

OBJECTIVES

Pediatric mental illness poses a significant burden with an overall prevalence of approximately 10%. Increasingly, children with mental disorders seek care in the emergency department (ED). However, the ED is not an ideal setting. Pediatric mental health patients receive limited treatment and experience significantly longer length of stay (LOS) than other patients seen in the ED. This study examines patient and hospital factors associated with LOS and prolonged LOS (PLOS).

METHODS

This is a retrospective chart review of patients between the ages of 3 and 17 presenting at 2 participating urban EDs with a psychiatric diagnosis from May 2010 to May 2012.

RESULTS

This study includes 939 patients with an average age of 14.1 years and a median LOS of 295 minutes. The diagnosis was the strongest predictor of LOS and PLOS. Patients with a psychotic disorder or suicide attempt or ideation experienced a longer LOS, 35% and 55% increases, respectively, and an increased odds of PLOS (odds ratio, 3.07 and 8.36, respectively). Patient sex, previous history of self-harm, and the daily census were associated with both a longer LOS and PLOS. Ethnicity, site of admission, and year of admission were only associated with LOS.

CONCLUSIONS

Diagnosis-specific management factors are the primary determinant of LOS. However, some patient characteristics and hospital operational factors are also associated with LOS. Organizational reforms and an evaluation of the required human and material resources are necessary to improve access to and availability of pediatric mental health care.

Substance abuse and mental health visits among adolescents presenting to US emergency departments

OBJECTIVES

The objectives of the study were to identify factors associated with adolescent emergency department (ED) visits for substance abuse, including those complicated by mental health (dual diagnosis), and to analyze their effect on ED length of stay (LOS) and disposition.

METHODS

We performed a secondary analysis of ED visits by adolescents (age, 11-24) using the National Hospital Ambulatory Medical Care Survey (1997-2010) to identify visits for mental health, substance use, and dual diagnosis. Univariate and multivariate statistics were used to analyze demographic and visit-level factors, factors associated with substance use and dual diagnosis visits, as well as the effects of substance use and mental health conditions on ED LOS and disposition.

RESULTS

Substance use and mental health accounted for 2.1% and 4.3% of all adolescent visits, respectively, with 20.9% (95% confidence interval [CI], 18.3%-23.5%) of substance abuse visits complicated by mental health. The factors significantly associated with substance use include the following: male sex, urban location, West region, ambulance arrival, night and weekend shift, anxiety disorders, mood disorders, and psychotic disorders. Additional LOS was 89.77 minutes for mental health, 71.33 minutes for substance use, and 139.97 minutes for dual diagnosis visits, as compared with visits where these conditions were not present. Both mental health and substance use were associated with admission/transfer as compared with other dispositions as follows: mental health odds ratio (OR), 5.93 (95% CI, 5.14-6.84); illicit drug use OR, 3.56 (95% CI 2.72-4.64); and dual diagnosis OR, 6.86 (95% CI, 4.67-10.09).

CONCLUSIONS

Substance abuse and dual diagnosis are common among adolescent ED visits and are strongly associated with increased use of prehospital resources, ED LOS, and need for hospitalization.

Children's Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay

Objective. This study explores the association of patient and emergency department (ED) mental health visit characteristics with wait time and length of stay (LOS). Methods. We examined data from 580 ED mental health visits made to two urban EDs by children aged ≤18 years from April 1, 2004, to March 31, 2006. Logistic regressions identified characteristics associated with wait time and LOS using hazard ratios (HR) with 95% confidence intervals (CIs). Results. Sex (male: HR = 1.48, 95% CI = 1.20-1.84), ED type (pediatric ED: HR = 5.91, 95% CI = 4.16-8.39), and triage level (Canadian Triage and Acuity Scale (CTAS) 2: HR = 3.62, 95% CI = 2.24-5.85) were statistically significant predictors of wait time. ED type (pediatric ED: HR = 1.71, 95% CI = 1.18-2.46), triage level (CTAS 5: HR = 2.00, 95% CI = 1.15-3.48), number of consultations (HR = 0.46, 95% CI = 0.31-0.69), and number of laboratory investigations (HR = 0.75, 95% CI = 0.66-0.85) predicted LOS. Conclusions. Based on our results, quality improvement initiatives to reduce ED waits and LOS for pediatric mental health visits may consider monitoring triage processes and the availability, access, and/or time to receipt of specialty consultations.

Temporal trends in pediatric mental health visits: using longitudinal data to inform emergency department health care planning

OBJECTIVE

Understanding the temporality of mental health presentations to the emergency department (ED) during the 24-hour cycle, day of the week, and month of the year may facilitate strategic planning of ED-based mental health services.

METHODS

Data on 30,656 ED presentations for mental illness, substance use, or intentional self-harm by 20,956 patients (≤ 17 years) were examined. We studied patient demography, discharge diagnosis, and time and date of presentation.

RESULTS

Most pediatric mental health ED visits (66.0%) occurred after the average work and school day (after 5 PM). Presentations related to substance use and intentional self-harm steadily increased in the evening. Emergency department visits related to substance use peaked on Friday through Sunday (4723/7475; 63.2%), whereas visits for mood disorders (4127/5093; 81.0%), neurotic/stress-related disorders (5960/7989; 74.6%), and behavioral/emotional disorders (237/304; 78%) were highest during the work/school week (Monday to Friday). Visits for intentional self-harm peaked following the weekend (Monday: 771/4676; 16.5%). Summer months had fewer visits (6862/30,656; 22.4%), whereas March to May (range: 2752-2912 visits) and October to November (range: 2701-2751 visits) showed more steady peaks in volume. Most presentations by diagnostic group decreased in volume during the winter months (December to February) to increase again in the spring (March to May).

CONCLUSIONS

Peak times for pediatric mental health presentations to the ED are evenings throughout the week, suggesting that mental health services for children, adolescents, and their families should be available after work and school hours, 7 days a week.