Improving mental health care transitions for children and youth: a protocol to implement and evaluate an emergency department clinical pathway

Youth Emergency Department and Inpatient Psychiatric Recidivism After Treatment in a Community-Based Crisis Program

OBJECTIVE

In emergency departments (EDs) nationwide, increasing numbers of youths in psychiatric crisis are "boarding," or awaiting psychiatric care in a nonpsychiatric setting. Community stabilization programs may reduce the prevalence of boarding while supporting behavioral health. This study aimed to evaluate ED and inpatient (IP) psychiatric recidivism of youths receiving Crisis and Transition Services (CATS), a community-based program providing in-home behavioral health crisis services.

METHODS

This retrospective matched cohort study used 2012-2020 medical claims data and linked program-collected data to compare CATS participants with nonparticipants (2018-2020). In total, 533 youths receiving CATS were matched to a control group (N=1,066) on initial ED visit date, reason for visit, age, and sex. Outcomes included time until first insurance claim for psychiatric or suicide attempt recidivism to an ED, IP admission, or both. Cox proportional hazard models were used to estimate the association between the outcomes of interest and CATS participation or nonparticipation up to 1 year following hospital (ED or IP) discharge.

RESULTS

CATS participation was significantly associated with reduced psychiatric recidivism to an ED, IP, or both, compared with nonparticipation, with significantly lower IP return admissions for suicide attempt.

CONCLUSIONS

Some boarding youths may be safely discharged to intensive community-based behavioral health crisis programs. Although return visits to EDs for suicide attempt did not differ between groups, youths in CATS had significantly lower hazards of IP admissions for suicide attempt. Comparable programs may reduce boarding without adding risk. Future studies should examine which individuals would benefit most from community-based treatment as well as key program components associated with outcomes.

Youth Mobile Response and Stabilization Services: Factors Associated with Multiple Episodes of Care

Mobile response and stabilization services (MRSS) provide short-term, community-based, care to individuals in crisis. Minimal studies have explored which factors are associated with multiple episodes of MRSS care. We used a retrospective cohort design of MRSS electronic health records to explore demographic and clinical characteristics associated with multiple episodes of care among 2,641 youth ages 5-21 years old in New York, USA. Youth with multiple episodes of care (n = 585; 22.2%) were more likely to be non-Hispanic, have treatment histories including presenting problems related to adjustment, conduct, mood, or suicidal thoughts and behaviors, have high-level mental health visits, and more follow-up visits. Future research should examine the unmet needs of non-Hispanic populations and whether characteristics associated with multiple MRSS episodes are consistent across populations to inform procedures targeting unmet needs that prevent or minimize repeated use during crises.

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

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Emergency Department Use by Children and Youth with Mental Health Conditions: A Health Equity Agenda

There are growing concerns regarding the referral of children and youth with mental health conditions to emergency departments (EDs). These focus on upward trends in utilization, uncertainty about benefits and negative effects of ED visits, and inequities surrounding this form of care. A review was conducted to identify and describe available types of data on ED use. The authors' interpretation of the literature is that it offers compelling evidence that children and youth in the U.S. are being sent to EDs for mental health conditions at increasing rates for reasons frequently judged as clinically inappropriate. As a major health inequity, it is infrequent that such children and youth are seen in EDs by a behavioral health professional or receive evidence-based assessment or treatment, even though they are kept in EDs far longer than those seen for reasons unrelated to mental health. The rate of increase in these referrals to EDs appears much greater for African American and Latinx children and youth than White children and is increasing for the publicly insured and uninsured while decreasing for the privately insured. A comprehensive set of strategies are recommended for improving healthcare quality and health equity. A fact sheet is provided for use by advocates in pressing this agenda.

"I Fell through the Cracks": Navigating the Disjointed Transition from Paediatric to Adult Psychiatric Services

The transition from adolescence to adulthood is a tumultuous time riddled with stress, confusion, and uncertainty. An abrupt shift in biobehavioural development between the ages of 16 and 24 corresponds with an increase in mental health challenges; thereby necessitating comprehensive and coordinated psychiatric services that bridge pediatric and adult care realms. Unfortunately, this transition is often unsupportive and disjointed, leaving many transitional-aged youth (TAY) overwhelmed and ill-equipped to cope with the increased demands of adulthood independently. Eight TAY with mental health challenges were invited to participate in a PhotoVoice study that explored the strengths and shortcomings of this transition process, through a combination of photography and photo-elicitation focus group discussions. A descriptive qualitative approach was used to analyze all participant dialogue. Four themes emerged from the data: accessibility, coordination, independence, and support. Participant insights illuminated critical gaps in mental health care delivery, but also revealed novel solutions and opportunities for transformational change.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework

BACKGROUND

delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol.

OBJECTIVES

we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients.

METHODS

we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified.

RESULTS

a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture.

CONCLUSION

this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Reducing length of stay and return visits for emergency department pediatric mental health presentations

BACKGROUND

Variability in expertise and risk tolerance among emergency departments (ED) clinicians, when assessing and managing pediatric mental health presentations, leads to increased resource utilization. HEARTSMAP is a validated electronic tool that supports ED clinicians in psychosocial assessments and disposition decision making.

METHODS

We used interrupted time series analysis (September 2016-December 2019) and multivariable regressions to measure the impact of integrating HEARTSMAP into ED practice on pediatric mental health presentations length of stay and return visits, at two pediatric EDs. The intervention site used HEARTSMAP trained ED clinicians to assess and manage mental health presentations, and reported bi-weekly ED median length of stay and 30 days-return visits for 15 months and a year, during passive and active implementation of HEARTSMAP, respectively. The control site used psychiatric nurses to assess and manage patients and was only exposed to passive implementation.

RESULTS

HEARTSMAP average uptake was on average 47.4% (range 23.8-74.6%) during active implementation at the intervention site, while the control site showed no uptake throughout the study period. Incremental HEARSTMAP (each percent increase) use was associated with a reduction of 1.8 min (95% CI 0.8-2.9 in ED length of stay and 0.3% (95% CI 0.2-0.5 in 30-day return visit rate. This translates to an adjusted average reduction of 85.3 min in ED length of stay and 15.2% in 30-day return visits for youth with mental health presentations.

CONCLUSION

Use of HEARTSMAP in the ED can decrease length of stay and return visits for emergency pediatric mental health visits, in a fixed-resource setting.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study

BACKGROUND

Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department.

METHODS

We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups.

RESULTS

Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001).

INTERPRETATION

Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study

OBJECTIVE

To document the rates of intentional self-harm and mental disorders among youths aged 13 to 17 years visiting Ontario emergency departments (EDs) from 2003-2017.

METHODS

This was a repeated cross-sectional observational design. Outcomes were rates of adolescents with (1) at least 1 self-harm ED visit and (2) a visit with a mental disorder code.

RESULTS

Rates of youths with self-harm visits fell 32% from 2.6/1000 in 2003 to 1.8 in 2009 but rose 135% to 4.2 by 2017. The slope of the trend in self-harm visits changed from -0.18 youths/1000/year (confidence interval [CI], -0.24 to -0.13) during 2003 to 2009 to 0.31 youths/1000/year (CI, 0.27 to 0.35) during 2009 to 2017 (P < 0.001). Rates of youths with mental health visits rose from 11.7/1000 in 2003 to 13.5 in 2009 (15%) and to 24.1 (78%) by 2017. The slope of mental health visits changed from 0.22 youths/1000/year (CI, 0.02 to 0.42) during 2003 to 2009 to 1.84 youths/1000/year (CI, 1.38 to 2.30) in 2009 to 2017 (P < 0.001). Females were more likely to have self-harm (P < 0.001) and mental health visits (P < 0.001). Rates of increase after 2009 were greater for females for both self-harm (P < 0.001) and mental health (P < 0.001).

CONCLUSIONS

Rates of adolescents with self-harm and mental health ED visits have increased since 2009, with greater increases among females. Research is required on the determinants of adolescents' self-harm and mental health ED visits and how they can be addressed in that setting. Sufficient treatment resources must be supplied to address increased demands for services.

Impact of Mobile Crisis Services on Emergency Department Use Among Youths With Behavioral Health Service Needs

OBJECTIVE

Youths are using emergency departments (EDs) for behavioral health services in record numbers, even though EDs are suboptimal settings for service delivery. In this article, the authors evaluated a mobile crisis service intervention implemented in Connecticut with the aim of examining whether the intervention was associated with reduced behavioral health ED use among those in need of services.

METHODS

The authors examined two cohorts of youths: 2,532 youths who used mobile crisis services and a comparison sample of 3,961 youths who used behavioral health ED services (but not mobile crisis services) during the same fiscal year. Propensity scores were created to balance the two groups, and outcome analyses were used to examine subsequent ED use (any behavioral health ED admissions and number of behavioral health ED admissions) in an 18-month follow-up period.

RESULTS

A pooled odds ratio of 0.75 (95% confidence interval [CI]=0.66-0.84) indicated that youths who received mobile crisis services had a significant reduction in odds of a subsequent behavioral health ED visit compared with youths in the comparison sample. The comparable result for the continuous outcome of number of behavioral health ED visits yielded an incidence risk ratio of 0.78 (95% CI=0.71-0.87).

CONCLUSIONS

Using comparison groups, the authors provided evidence suggesting that community-based mobile crisis services, such as Mobile Crisis, reduce ED use among youths with behavioral health service needs. Replication in other years and locations is needed. Nevertheless, these results are quite promising in light of current trends in ED use.

Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth

Background

This article describes the provincial dissemination of HEARTSMAP, an evidence-based emergency department (ED) psychosocial assessment and disposition decision tool for clinician use with children and youth.

Methods

HEARTSMAP was disseminated in partnership with local, child and youth mental health teams, as part of a quality improvement initiative implemented in British Columbia EDs. The target audience of education sessions were clinicians working in ED settings responsible for paediatric psychosocial assessments. We used the RE-AIM framework to evaluate the reach, effectiveness, adoption, implementation, and maintenance of HEARTSMAP dissemination, analyzing data from session evaluation forms and online tool data.

Results

Education sessions reached 475 attendees, in 52 of 95 British Columbia EDs. HEARTSMAP training was well received by clinicians with 96% describing effective content including increased comfort in conducting paediatric psychosocial assessments and confidence in disposition planning after training. Clinicians identified unclear processes and lack of local resources as the main barriers to implementation. One-third of the attendees expressed willingness to use the tool, and 27% of registered clinicians have used the tool postimplementation.

Conclusions

Our approach reached and effectively trained clinicians from over half of the province's EDs to use HEARTSMAP for emergency paediatric psychosocial assessments. For some, this provided greater comfort and confidence for these assessments and the following disposition decisions. This evaluation provides valuable insights on training clinicians to use a paediatric mental health tool within diverse ED settings and emphasized the need for ongoing support and institutional engagement to facilitate local, infrastructural, and operational processes for adoption and maintenance, postdissemination.

Family Factors and Repeat Pediatric Emergency Department Visits for Mental Health: A Retrospective Cohort Study

OBJECTIVES

Approximately 45% of youth presenting to the emergency department (ED) for mental health (MH) concerns will have a repeat ED visit. Since youth greatly depend on their caregivers to access MH services, the objective of this study was to determine if family characteristics were associated with repeat ED visits.

METHODS

A retrospective cohort study of youth aged 6-18 years (62% female) treated at a tertiary pediatric ED for a discharge diagnosis related to MH was conducted. Data were gathered from medical records, telephone interviews, and questionnaires. Family factor contribution was analyzed using a multivariable logistic regression model controlling for demographic, clinical and service utilization factors. Variables associated with earlier and more frequent visits were determined using cox regression and negative binomial regression.

RESULTS

Of 266 participants, 70 (26%) had a repeat visit. While caregiver history of MH treatment decreased the odds of having a repeat ED visit, family functioning and perceived family burden were not associated with repeat visits. Post-visit MH services, prior psychiatric hospitalization, higher severity of symptoms, and living closer to the hospital increased the odds of repeat visits.

CONCLUSIONS

This study examined the contribution of multiple family factors in predicting repeat MH visits to the ED. Results suggest caregiver characteristics may impact the decision to return. Healthcare providers should therefore consider caregiver and youth service utilization factors to inform patient management and discharge planning.

Emergency Department Presentations and Youth Suicide: A Case-Control Study

OBJECTIVE

We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care.

METHOD

This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.

RESULTS

Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days.

CONCLUSIONS

The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

Evaluating the HEADS-ED Screening Tool in a Hospital-Based Mental Health and Addictions Central Referral Intake System: A Prospective Cohort Study

OBJECTIVES

We evaluated the use of a mental health (MH) screening tool in a hospital-based centralized MH referral telephonic intake process. The tool is used to guide psychosocial screening in several domains: home; education; activities and peers; drugs and alcohol; suicidality; emotions, thoughts, and behaviors; and discharge resources (HEADS-ED). We wanted to understand the use of the tool to guide next step in care decision-making over the telephone.

METHODS

Intake workers used the HEADS-ED tool to guide the assessment processes, identified areas of MH need, and made decisions about next step in care. We completed a retrospective chart review of all callers to the intake system over 4 months to gather initial decision at intake and subsequent steps in treatment. χ² and analysis of variance tests were used to examine differences between HEADS-ED scores and next step in care.

RESULTS

A total of 674 patients aged 3 to 19 years (mean age = 11.7 years, SD = 0.6; girls = 50.0%) called for services. Significant mean differences were found on total HEADS-ED scores between treatment options (F_4,641 = 75.76; P < .001). Decision validity indicated that 86% (n = 506 of 587) of initial referrals matched treatments that were actually received. Uptake of the tool was 100%, and interrater reliability indicated strong agreement between raters (intraclass correlation coefficient = 0.82; P < .001).

CONCLUSIONS

With our results, we support the use of the HEADS-ED tool in a telephone-based MH intake system to help guide the initial assessment and inform decision-making about fit of next step in care, both within the health center-based MH system and in the community.

Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review

OBJECTIVE

Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings.

DESIGN

Systematic review.

DATA SOURCES

PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane.

METHODS

We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction.

RESULTS

Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions.

CONCLUSIONS

Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence.

Current Pediatric Emergency Department Innovative Programs to Improve the Care of Psychiatric Patients

Emergency departments (EDs) across North America have become a safety net for patients seeking mental health (MH) services. The prevalence of families seeking treatment of children in MH crisis has become a national emergency. To address MH access and improve quality and efficient management of children with MH conditions, the authors describe ED projects targeting this vulnerable population. Five North American health care systems volunteered to feature projects that seek to reduce ED visits and/or improve the care of MH patients: Allina Health, Nationwide Children's Hospital, Children's Hospital of Eastern Ontario, Connecticut Children's Medical Center, and Rhode Island Hospital.

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.