The burden of mental and behavioral health visits to the pediatric ED: A 3-year tertiary care center experience

Challenges and facilitators in child-friendly healthcare from the perspective of pediatric emergency nurses: A qualitative study

PURPOSE

This study aimed to determine pediatric emergency nurses' experiences and opinions regarding child-friendly care within Watson's Human Care Model framework.

DESIGN AND METHODS

This study is qualitative research conducted with nurses in the pediatric emergency unit of a university hospital between 06 March and 06 April 2024. This study used a purposive sampling method and conducted semi-structured interviews with 17 nurses. All interviews were audio recorded and transcribed. Inductive thematic analysis method was used. The study was written based on the COREQ checklist.

FINDINGS

This study determined two themes, five sub-themes, and 13 categories. The theme "challenges to child-friendly healthcare implementation" included a lack of physical space and agitated and violent families. It has been reported that physical space, especially where privacy is not protected, makes child-friendly care complex, and the violent reactions of families are significant obstacles. The second theme, "facilitators for an ideal child-friendly pediatric emergency unit," included the design of the pediatric emergency unit/improving physical environment, availability of appropriate equipment, and effective communication strategies. This theme emphasizes the importance of colorfully designing the physical space and equipment in a way that does not scare children.

CONCLUSION

It has been determined that the healing environment and care processes are essential for child-friendly care. During the care processes, communication according to the age of the children and communication with agitated families was emphasized as an essential component of care.

PRACTICE IMPLICATIONS

The study results will guide hospital management, healthcare professionals working in the field, and future studies on designing the child-friendly emergency unit that children deserve.

From Their Perspective: Pediatric Patients With Acute Mental Health Needs and Prolonged Emergency Department Stays

BACKGROUND

The pediatric emergency department (PED) is experiencing a rising volume of patients with mental health concerns, leading to prolonged boarding times and delays in initiating active therapeutic plans. A paucity of research exists for the self-reported pediatric patient experience during such boarding.

OBJECTIVES

To inform more individualized and patient-centered PED care for patients boarding for mental health admission, by learning the prior trauma experiences and patient perspective on prolonged PED mental health stays.

METHODS

A convenience sample was collected at an urban hospital's PED among those boarding for mental health emergency greater than 24 hours. Demographic information, exposures to past trauma, and perceptions on and understanding of their care experience, were discussed. Descriptive and thematic content analysis were used for data analysis.

RESULTS

A total of 99 youths were included in the study and the majority reported worsening mental health symptoms during PED boarding, notably increasing anxiety (72 [72.7%]). Patients were equivocal on efficacy of PED mental health intake on symptoms (41 [41.4%]). Personal suggestions were offered by these patients to guide the care of future children that would better mitigate their symptoms while boarding in the PED, such as group activities, electronics, and physical activity.

DISCUSSION

Patients in mental health crisis boarding in the PED have already experienced stressful life events. By listening to the personal stories of this vulnerable population, the PED can improve care delivery and design a more therapeutic environment, especially as the need for acute mental health management continues to increase.

Development and Implementation of a Pediatric Nursing Emergency Behavioral Health Assessment Tool

INTRODUCTION

The national pediatric mental and behavioral health crisis dramatically increased emergency department mental and behavioral health visits and changed emergency nursing practice. Acuity assessment determines patient severity level and supports appropriate resources and interventions. There are no established nursing tools that assess pediatric mental or behavioral health acuity in the emergency department setting. Our goal was to develop and implement the novel pediatric emergency nurse Emergency Behavioral Health Acuity Assessment Tool.

METHODS

This quality-improvement project used the plan, do, study, act model to design/refine the Emergency Behavioral Health Acuity Assessment Tool and a non-experimental descriptive design to assess outcomes. The setting was a 47-bed urban level 1 pediatric trauma center with more than 60,000 annual visits. The team designed the tool using published evidence, emergency nurse feedback, and expert opinion. The tool objectively captured patient acuity and suggested acuity-specific nursing interventions. Project outcomes included acuity, length-of-stay, restraint use, and patient/staff injuries. Analyses included descriptive statistics and correlations.

RESULTS

With over 3000 annual mental/behavioral-related visits, the emergency department had an average daily census of 23 mental and behavioral health patients. Implementation occurred in August 2021. The Emergency Behavioral Health Acuity Assessment Tool dashboard provided the number of patients, patient location, and acuity. Length-of-stay did not change; however, patient restraint use and patient/staff injuries declined. Number of restraints positively correlated with moderate acuity levels (r = 0.472, P = 0.036).

DISCUSSION

For emergency nurses, the Emergency Behavioral Health Acuity Assessment Tool provided an objective measure of patient acuity. Targeted interventions can improve the care of this population.

Reducing Pediatric Mental Health Boarding and Increasing Acute Care Access

BACKGROUND

There have been notable increases in pediatric mental health boarding in the United States in recent years, with youth remaining in emergency departments or admitted to inpatient medical/surgical units, awaiting placement in psychiatric treatment programs.

OBJECTIVES

We aimed to evaluate the outcomes of interventions to reduce boarding and improve access to acute psychiatric services at a large tertiary pediatric hospital during a national pediatric mental health crisis.

METHODS

Boarding interventions included expanding inpatient psychiatric beds and hiring additional staff for enhanced crisis stabilization services and treatment initiation in the emergency department and on inpatient medical/surgical units for boarding patients awaiting placement. Post-hoc assessment was conducted via retrospective review of patients presenting with mental health emergencies during the beginning of intervention implementation in October-December 2021 and one year later (October-December 2022). Inclusion criteria were patients ≤17 years who presented with mental health-related emergencies during the study period. Exclusion criteria were patients ≥18 years and/or patients with >100 days of admission awaiting long-term placement. Primary outcome was mean length of boarding (LOB). Secondary outcome was mean length of stay (LOS) at the hospital's acute psychiatry units.

RESULTS

One year after full intervention implementation (October-December 2022), mean LOB decreased by 53% (4.3 vs 9.1 days, P < 0.0001) for boarding patients discharged to high (e.g., inpatient, acute residential) and intermediate (e.g., partial hospital, in-home crisis stabilization programs) levels of care, compared to October-December 2021. Additionally, mean LOS at all the 24-hour acute psychiatry treatment programs was reduced by 27% (20.0 vs 14.6 days, P = 0.0002), and more patients were able to access such programs (265/54.2% vs 221/41.9%, P < 0.0001). Across both years, youth with aggressive behaviors had 193% longer LOB (2.93 ± 1.15, 95% CI [2.23, 3.87]) than those without aggression, and youth with previous psychiatric admissions had 88% longer LOB than those without (1.88 ± 1.11, 95% CI [1.54, 2.30]).

CONCLUSIONS

The current study shows decreased LOB and improved access for youth requiring acute psychiatric treatment after comprehensive interventions and highlights challenges with placement for youth with aggressive behaviors. We recommend a call-to-action for pediatric hospitals to commit sufficient investment in acute psychiatric resources to address pediatric mental health boarding.

Impact of mental health boarding on clinicians at a children's hospital: A qualitative analysis

BACKGROUND

The child and adolescent mental health boarding crisis (i.e., prolonged stays in acute care hospitals for patients awaiting mental health treatment) continues to challenge acute care hospital staff and resources. We sought to understand clinician's experiences while caring for patients experiencing mental health boarding.

METHODS

We conducted semistructured qualitative interviews with clinicians who care for patients experiencing mental health boarding in an acute care freestanding children's hospital with no inpatient psychiatric unit. We used an inductive approach to determine interview themes and major findings.

RESULTS

The study included 48 clinician participants from diverse specialties, including 13 social workers, 11 nurses, five psychiatric technicians, six pediatric residents, four attending pediatric hospitalists, four attending psychiatrists, one psychologist, and four other mental health specialists. We identified emergent themes in five domains: (1) frustrations with the mental healthcare system, (2) lack of training in mental healthcare skills, (3) feelings of helplessness, (4) ineffectiveness of medical model of care during mental health boarding, and (5) resilience and support factors.

CONCLUSIONS

Caring for patients with mental health boarding has negative effects on clinicians, and health system efforts to prevent boarding could improve workforce retention and reduce burnout.

Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where

Objectives

Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions.

Methods

This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods.

Results

Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods.

Conclusions

Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.