Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation

OBJECTIVES

Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs.

METHODS

At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital.

RESULTS

We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals.

CONCLUSIONS

Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

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.

Improving Documentation of Firearm Access During Pediatric Emergency Visits for Suicidal Ideation

BACKGROUND AND OBJECTIVES

Approximately half of youth suicides involve firearms. The promotion of safe firearm storage in the home through lethal means counseling reduces suicide risk. We aimed to increase the documentation of firearm access and storage among children presenting to the emergency department (ED) with suicidal ideation or self-injury to 80% within 13 months.

METHODS

We conducted a multidisciplinary quality improvement initiative to improve the documentation of firearm access and storage among children <18 years old seen in the ED for suicidal ideation or self-injury. The baseline period was February 2020 to September 2021, and interventions occurred through October 2022. Interventions included adding a templated phrase about firearm access to psychiatric social work consult notes and the subsequent modification of the note to include all firearm storage elements (ie, locked, unloaded, separate from ammunition). Statistical process control and run charts were generated monthly to monitor the documentation of firearm access and storage, which was measured through a review of keyword snippets extracted from note text.

RESULTS

We identified 2158 ED encounters for suicidal ideation or self-injury during the baseline and intervention periods. Documentation of firearm access increased from 37.8% to 81.6%, resulting in a centerline shift. Among families who endorsed firearm access, the documentation of firearm storage practices increased from 50.0% to 78.0%, resulting in a centerline shift.

CONCLUSIONS

The modification of note templates facilitated increased documentation of firearm access and storage practices for children with suicidal ideation in the ED. Future studies should assess whether improved documentation is associated with improved storage practices and reductions in firearm suicides after ED encounters.

A Qualitative Assessment of Barriers and Proposed Interventions to Improve Acute Agitation Management for Children With Mental and Behavioral Health Conditions in the Emergency Department

BACKGROUND

Mental health visits to the emergency department (ED) by children are rising in the United States, and acute agitation during these visits presents safety risks to patients and staff.

OBJECTIVE

We sought to assess barriers and strategies for providing high-quality care to children who experience acute agitation in the ED.

METHODS

We conducted semistructured interviews with 6 ED physicians, 6 ED nurses, 6 parents, and 6 adolescents at high risk for developing agitation. We asked participants about their experiences with acute agitation care in the ED, barriers and facilitators to providing high-quality care, and proposed interventions. Interviews were coded and analyzed thematically.

RESULTS

Participants discussed identifying risk factors for acute agitation, worrying about safety and the risk of injury, feeling moral distress, and shifting the culture toward patient-centered, trauma-informed care. Barriers and facilitators included using a standardized care pathway, identifying environmental barriers and allocating resources, partnering with the family and child, and communicating among team members. Nine interventions were proposed: opening a behavioral observation unit with dedicated staff and space, asking screening questions to identify risk of agitation, creating personalized care plans in the electronic health record, using a standardized agitation severity scale, implementing a behavioral response team, providing safe activities and environmental modifications, improving the handoff process, educating staff, and addressing bias and inequities.

CONCLUSIONS

Understanding barriers can inform solutions to improve care for children who experience acute agitation in the ED. The perspectives of families and patients should be considered when designing interventions to improve care.

Evaluation and management of suicidal ideation and self-harm in children in the emergency department

Suicide is a leading cause of death among youth, and the emergency department (ED) serves as the primary point of healthcare contact for many with suicidal ideation. As suicide-related presentations to the ED continue to rise, the implementation of time- and cost-effective care pathways becomes ever more critical. Evidence-based tools for the identification and stratification of suicide risk can aid in clinical decision-making and care linkage. This issue reviews best practices for suicide risk assessment of youth to guide evaluation, management, and disposition planning within the ED setting.

Characteristics of pediatric behavioral health emergencies in the prehospital setting

OBJECTIVE

Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.

METHODS

We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use.

RESULTS

Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61).

CONCLUSIONS

Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants

Importance

Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language.

Objective

To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection.

Design, Setting, and Participants

This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source.

Exposures

Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English).

Main Outcomes and Measures

The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes.

Results

Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46).

Conclusions and Relevance

Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Pediatric Firearm Injury Emergency Department Visits From 2017 to 2022: A Multicenter Study

BACKGROUND AND OBJECTIVE

Pediatric firearm injuries increased during the coronavirus disease 2019 pandemic, but recent trends in firearm injury emergency department (ED) visits are not well described. We aimed to assess how pediatric firearm injury ED visits during the pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied firearm injury ED visits by children <18 years old at 9 US hospitals participating in the Pediatric Emergency Care Applied Research Network Registry before (January 2017 to February 2020) and during (March 2020 to November 2022) the pandemic. Multivariable Poisson regression models estimated expected visit rates from prepandemic data. We calculated rate ratios (RRs) of observed to expected visits per 30 days, overall, and by sociodemographic characteristics.

RESULTS

We identified 1904 firearm injury ED visits (52.3% 15-17 years old, 80.0% male, 63.5% non-Hispanic Black), with 694 prepandemic visits and 1210 visits during the pandemic. Death in the ED/hospital increased from 3.1% prepandemic to 6.1% during the pandemic (P = .007). Firearm injury visits per 30 days increased from 18.0 prepandemic to 36.1 during the pandemic (RR 2.09, 95% CI 1.63-2.91). Increases beyond expected rates were seen for 10- to 14-year-olds (RR 2.61, 95% CI 1.69-5.71), females (RR 2.46, 95% CI 1.55-6.00), males (RR 2.00, 95% CI 1.53-2.86), Hispanic children (RR 2.30, 95% CI 1.30-9.91), and Black non-Hispanic children (RR 1.88, 95% CI 1.34-3.10).

CONCLUSIONS

Firearm injury ED visits for children increased beyond expected prepandemic trends, with greater increases among certain population subgroups. These findings may inform firearm injury prevention efforts.

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.

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.

Timing of Mental Health Service Use After a Pediatric Firearm Injury

OBJECTIVES

To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics.

METHODS

We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics.

RESULTS

After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65).

CONCLUSIONS

More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators

OBJECTIVE

Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care.

METHODS

We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California.

RESULTS

PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%).

CONCLUSIONS

ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.

Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department

BACKGROUND AND OBJECTIVES

Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints.

METHODS

A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints.

RESULTS

During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71.

CONCLUSIONS

Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.

Racial and Ethnic Differences in Insurer Classification of Nonemergent Pediatric Emergency Department Visits

Importance

Government and commercial health insurers have recently enacted policies to discourage nonemergent emergency department (ED) visits by reducing or denying claims for such visits using retrospective claims algorithms. Low-income Black and Hispanic pediatric patients often experience worse access to primary care services necessary for preventing some ED visits, raising concerns about the uneven impact of these policies.

Objective

To estimate potential racial and ethnic disparities in outcomes of Medicaid policies for reducing ED professional reimbursement based on a retrospective diagnosis-based claims algorithm.

Design, Setting, and Participants

This simulation study used a retrospective cohort of pediatric ED visits (aged 0-18 years) for Medicaid-insured children and adolescents appearing in the Market Scan Medicaid database between January 1, 2016, and December 31, 2019. Visits missing date of birth, race and ethnicity, professional claims data, and Current Procedural Terminology codes of billing level of complexity were excluded, as were visits that result in admission. Data were analyzed from October 2021 to June 2022.

Main Outcomes and Measures

Proportion of ED visits algorithmically classified as nonemergent and simulated per-visit professional reimbursement after applying a current reimbursement reduction policy for potentially nonemergent ED visits. Rates were calculated overall and compared by race and ethnicity.

Results

The sample included 8 471 386 unique ED visits (43.0% by patients aged 4-12 years; 39.6% Black, 7.7% Hispanic, and 48.7% White), of which 47.7% were algorithmically identified as potentially nonemergent and subject to reimbursement reduction, resulting in a 37% reduction in ED professional reimbursement across the study cohort. More visits by Black (50.3%) and Hispanic (49.0%) children were algorithmically identified as nonemergent when compared with visits by White children (45.3%; P < .001). Modeling the impact of the reimbursement reductions across the cohort resulted in expected per-visit reimbursement that was 6% lower for visits by Black children and 3% lower for visits by Hispanic children relative to visits by White children.

Conclusions and Relevance

In this simulation study of over 8 million unique ED visits, algorithmic approaches for classifying pediatric ED visits that used diagnosis codes identified proportionately more visits by Black and Hispanic children as nonemergent. Insurers applying financial adjustments based on these algorithmic outputs risk creating uneven reimbursement policies across racial and ethnic groups.

Follow-up After Pediatric Mental Health Emergency Visits

OBJECTIVES

To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.

METHODS

We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).

RESULTS

Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.

CONCLUSIONS

Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Using Hospital Incident Command Systems to Respond to the Pediatric Mental and Behavioral Health Crisis of the COVID-19 Pandemic

ABSTRACT

Hospital incident command systems (HICS) were implemented to expand mental and behavioral healthcare (MBHC) services during the COVID-19 pandemic. Data on patient census, nurse vacancies, staff injuries, and staff perceptions were analyzed to quantify issues and track progress toward HICS goals. Data, environment of care, staffing, staff support, staff education, and communication resources were developed. After HICS implementation, 84% of nurses reported confidence in providing care to youth with acute MBHC needs. Nurse leaders should consider HICS for addressing other crises.

Association of Youth Suicides and County-Level Mental Health Professional Shortage Areas in the US

Importance

Suicide is the second leading cause of death among US adolescents. Workforce shortages of mental health professionals in the US are widespread, but the association between mental health workforce shortages and youth suicides is not well understood.

Objective

To assess the association between youth suicide rates and mental health professional workforce shortages at the county level, adjusting for county demographic and socioeconomic characteristics.

Design, Setting, and Participants

This retrospective cross-sectional study included all US counties and used data of all US youlth suicides from January 2015, through December 31, 2016. Data were analyzed from July 1, 2021, through December 20, 2021.

Exposures

County health-professional shortage area designation for mental health, assigned by the US Health Resources and Services Administration based on mental health professionals relative to the population, level of need for mental health services, and service availability in contiguous areas. Designated shortage areas receive a score from 0 to 25, with higher scores indicating greater workforce shortages.

Main Outcomes and Measures

Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention's Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children's mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score.

Results

During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06).

Conclusions and Relevance

In this cross-sectional study, US county mental health professional workforce shortages were associated with increased youth suicide rates. These findings may inform suicide prevention efforts.

Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments

OBJECTIVES

Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described.

METHODS

This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint.

RESULTS

Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25).

CONCLUSIONS

For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.

A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings

OBJECTIVE

Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings.

METHODS

A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions.

RESULTS

A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical.

CONCLUSIONS

Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.

Warning Labels and High-Powered Magnet Exposures

BACKGROUND AND OBJECTIVES

High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk.

METHODS

Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk.

RESULTS

Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children's toys and only 6.9% knew high-powered magnets were previously removed from the United States market.

CONCLUSIONS

Over 90% of subjects from the IMPACT study didn't know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children's toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Neighborhood Child Opportunity and Emergency Department Utilization

The Child Opportunity Index measures the structural neighborhood context that may influence a child's healthy development. We examined relationships between the Child Opportunity Index and emergency department utilization.

BACKGROUND AND OBJECTIVES

The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample.

METHODS

This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission.

RESULTS

We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]).

CONCLUSIONS

Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.

Career Development in Pediatric Emergency Medicine: What Do We Need?

OBJECTIVES

The Women in Pediatric Emergency Medicine (PEM) subcommittee of the American Academy of Pediatrics Section on Emergency Medicine identified 2 top priorities for 2021: career development and mentorship/sponsorship. The objective of this study was to catalog and delineate the career development domains for women physicians in PEM.

METHODS

After a review of the literature to identify the key areas for gaps for women in PEM, we used Q sort methodology to elicit domains for this subcommittee to address by survey of a national sample.

RESULTS

One hundred fourteen discrete potential areas of interest for career development were identified by the working group based on salient themes from the literature and personal experiences. Forty-one Women in PEM subcommittee members (27%) completed the survey. The career development topics were sorted into the domains of personal (40.4%; n = 46), administrative (28.1%; n = 32), research (10.5%; n = 12), teaching (10.5%; n = 12), service (7.0%; n = 8), and clinical (3.5%; n = 4).

CONCLUSIONS

This study demonstrates that the career development needs of women in PEM include a range of personal, teaching, research, administrative, clinical, and service domains. However, more than two-thirds of the career development topics were categorized into just 2 domains, administrative and personal.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies

OBJECTIVE

To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC).

BACKGROUND

A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury.

METHODS

We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms.

RESULTS

We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76).

CONCLUSIONS

Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Development of Quality Measures for Pediatric Agitation Management in the Emergency Department

OBJECTIVE

Pediatric mental health emergency department (ED) visits that involve restraints for agitation are increasing. Quality measures are used to assess and improve healthcare quality. Our objective was to develop quality measures for pediatric ED agitation management informed by multidisciplinary perspectives.

METHODS

A multidisciplinary panel developed quality measures for pediatric ED agitation management through the modified Delphi method. Panelists ranked measures in importance and feasibility on a 9-point scale during 2 survey rounds, with a teleconference discussion between surveys. Consensus was defined by >75% of panelists ranking a quality measure highly (≥7) in importance and a median feasibility score of ≥4.

RESULTS

Panelists included 36 physicians, nurses, social workers, security, child life specialists, hospital data analysts, and parents. The panel reached consensus on 20 quality measures. Measures with the highest percentage of scores with importance ≥7 were related to adverse medication events, patients restrained, staff/patient injuries, reescalation plans, presence of an algorithm to standardize care, formal staff training on deescalation techniques, time to medication administration, and room safety.

CONCLUSIONS

Twenty quality measures that incorporate multidisciplinary perspectives were developed for pediatric ED agitation management. Once operationalized and field tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.

Reducing Pediatric Emergency Department Prescription Errors

BACKGROUND

Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines.

METHODS

From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing.

RESULTS

Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased.

CONCLUSION

QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study

BACKGROUND AND OBJECTIVES

High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market.

METHODS

This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019.

RESULTS

Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality.

CONCLUSIONS

Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

Association of County-Level Poverty and Inequities With Firearm-Related Mortality in US Youth

IMPORTANCE

Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however.

OBJECTIVE

To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention's Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020.

EXPOSURES

County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level.

MAIN OUTCOMES AND MEASURES

The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated.

RESULTS

A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3 833 105 years of potential life lost was observed.

CONCLUSIONS AND RELEVANCE

This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.

Mental Health Emergency Department Visits by Children Before and During the COVID-19 Pandemic

OBJECTIVES

To describe pediatric mental health emergency department (ED) visit rates and visit characteristics before and during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study of ED visits by children 5-17 years old with a primary mental health diagnosis from March 2018 to February 2021 at a 10-hospital health system and a children's hospital in the Chicago area. We compared demographic and clinical characteristics of children with mental health ED visits before and during the pandemic. We conducted an interrupted time series analysis to determine changes in visit rates.

RESULTS

We identified 8,127 pediatric mental health ED visits (58.5% female, 54.3% White, Not Hispanic/Latino and 42.4% age 13-15). During the pandemic, visits for suicide or self-injury increased 6.69% (95% CI 4.73, 8.65), and visits for disruptive, impulse control, conduct disorders increased 1.94% (95% CI 0.85, 3.03). Mental health ED visits by children with existing mental health diagnoses increased 2.29% (95% CI 0.34, 4.25). Mental health ED visits that resulted in medical admission increased 4.32% (95% CI 3.11, 5.53). The proportion of mental health ED visits at community hospitals increased by 5.49% (95% CI 3.31, 7.67). Mental health ED visit rates increased at the onset of the pandemic (adjusted incidence rate ratio [aIRR] 1.27, 95% CI 1.06, 1.50), followed by a monthly increase thereafter (aIRR 1.04, 95% CI 1.02, 1.06).

CONCLUSION

Mental health ED visit rates by children increased during the COVID-19 pandemic. Changes in mental health ED visit characteristics during the pandemic may inform interventions to improve children's mental health.

Emergency Department Visits for Suicidal Ideation and Self-Harm in Rural and Urban Youths

OBJECTIVES

To compare emergency department (ED) visit rates for suicidal ideation and/or self-harm among youth by urban-rural location of residence.

STUDY DESIGN

This is a retrospective analysis of ED visits for suicidal ideation and/or self-harm by youths aged 5-19 years (n = 297 640) in the 2016 Nationwide Emergency Department Sample, a representative sample of all US ED visits. We used weighted Poisson generalized linear models to compare population-based visit rates by urban-rural location of patient residence, adjusted for age, sex, and US Census region. For self-harm visits, we compared injury mechanisms by urban-rural location.

RESULTS

Among patients with ED visits for suicidal ideation and/or self-harm, the median age was 16 years, 65.9% were female, 15.9% had a rural location of patient residence, and 0.1% resulted in mortality. The adjusted ED visit rate for suicidal ideation/or and self-harm did not differ significantly by urban-rural location. For the subset of visits for self-harm, the adjusted visit rate was significantly higher in small metropolitan (adjusted incidence rate ratio [aIRR], 1.39; 95% CI, 1.01-1.90), micropolitan (aIRR, 1.46; 95% CI, 1.10-1.93), and noncore areas (aIRR, 1.39; 95% CI, 1.03-1.87) compared with large metropolitan areas. When stratified by injury mechanism, ED visit rates for self-inflicted firearm injuries were higher among youths living in rural areas compared with those in urban areas (aIRR, 3.03; 95% CI, 1.32-6.74).

CONCLUSIONS

Compared with youths living in urban areas, youths living in rural areas had higher ED visit rates for self-harm, including self-inflicted firearm injuries. Preventive approaches for self-harm based in community and ED settings might help address these differences.

Pharmacologic Restraint Use During Mental Health Visits in Pediatric Emergency Departments

OBJECTIVES

To evaluate the trends and hospital variation in the use of pharmacologic restraint among pediatric mental health visits in the emergency department (ED).

STUDY DESIGN

We examined ED visits with a mental health diagnosis in patients aged 3-21 years at children's hospital EDs from 2009 to 2019. We calculated the frequency of pharmacologic restraint use and determined visit characteristics associated with restraint use. We calculated cumulative percent change for visits with restraints and for all mental health visits. We used logistic regression to test trends over time and evaluate hospital variation in the frequency of restraint use.

RESULTS

We identified 389 885 mental health ED visits (54.9% female, median age 14.3 years) and 13 643 (3.5%) visits with pharmacologic restraint use. Characteristics associated with pharmacologic restraint use were late adolescent age (18-21 years), male sex, Black race, non-Latino ethnicity, public insurance, and admission to the hospital (P < .001). During the study period, both mental health ED visits increased by 268% and mental health ED visits with pharmacologic restraint use increased by 370%. The rate of pharmacologic restraint in this patient population remained constant. Hospital use of pharmacologic restraint for mental health visits varied significantly across hospitals (1.6%-11.8%, P < .001).

CONCLUSIONS

Pediatric mental health ED visits with and without pharmacologic restraint are increasing over time. In addition, the overall number of pharmacologic restraint use has increased threefold. Significant hospital variation in pharmacologic restraint use signifies an opportunity for standardization of care and restraint reduction.

Pharmacologic Management of Acute Agitation in Youth in the Emergency Department

ABSTRACT

When youth in the emergency department become acutely agitated, it can be dangerous and distressing to patients, families, and clinicians. Timely, effective, and patient-centered management is key to reducing the potential for patient and staff injury while preserving patient dignity. We review the definition of agitation and pharmacologic management for youth with acute agitation, including common classes of medications, indications for use, and adverse effects. We also discuss the need to integrate the use of medications into a comprehensive strategy for agitation management that begins with proactive prevention of aggressive behavior, creation of a therapeutic treatment environment, and verbal de-escalation strategies.

A Teenager With Acute Anterograde Amnesia

Isolated amnesia is an uncommon presenting complaint in the pediatric age group. We report the case of an 18-year-old woman who presented with the acute onset of memory difficulty and an otherwise normal neurologic examination. Brain magnetic resonance imaging demonstrated inflammation in the bilateral temporal lobes. Serum and cerebrospinal fluid testing ultimately revealed a diagnosis of autoimmune encephalitis. Although rare, the acute onset of isolated amnesia deserves a prompt, comprehensive evaluation.

Association of Pediatric Suicide With County-Level Poverty in the United States, 2007-2016

IMPORTANCE

Suicide is the second leading cause of death among youths aged 10 to 19 years in the United States, with rates nearly doubling during the past decade. Youths in impoverished communities are at increased risk for negative health outcomes; however, the association between pediatric suicide and poverty is not well understood.

OBJECTIVE

To assess the association between pediatric suicide rates and county-level poverty concentration.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional study examined suicides among US youths aged 5 to 19 years from January 1, 2007, to December 31, 2016. Suicides were identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes from the Centers for Disease Control and Prevention's Compressed Mortality File. Data analysis was performed from February 1, 2019, to September 10, 2019.

EXPOSURES

County poverty concentration and the percentage of the population living below the federal poverty level. Counties were divided into 5 poverty concentration categories: 0% to 4.9%, 5.0% to 9.9%, 10.0% to 14.9%, 15.0% to 19.9%, and 20.0% or more of the population living below the federal poverty level.

MAIN OUTCOMES AND MEASURES

The study used a multivariable negative binomial regression model to analyze the association between pediatric suicide rates and county poverty concentration, reporting adjusted incidence rate ratios (aIRRs) with 95% CIs. The study controlled for year, demographic characteristics of the children who died (age, sex, and race/ethnicity), county urbanicity, and county demographic features (age, sex, and racial composition). Subgroup analyses were stratified by method.

RESULTS

From 2007 to 2016, a total of 20 982 youths aged 5 to 19 years died by suicide (17 760 [84.6%] were aged 15-19 years, 15 982 [76.2%] male, and 14 387 [68.6%] white non-Hispanic). The annual suicide rate was 3.35 per 100 000 youths aged 5 to 19 years. In the multivariable model, compared with counties with the lowest poverty concentration (0%-4.9%), counties with poverty concentrations of 10% or greater had higher suicide rates in a stepwise manner (10.0%-14.9%: aIRR, 1.25 [95% CI, 1.06-1.47]; 15.0%-19.9%: aIRR, 1.30 [95% CI, 1.10-1.54]; and 20.0% or more: aIRR, 1.37 [95% CI, 1.15-1.64]). When stratified by method, firearm suicides had the strongest association with county poverty concentration (aIRR, 1.87; 95% CI, 1.41-2.49) in counties with 20% or higher poverty concentration compared with counties with 0% to 4.9% poverty concentration.

CONCLUSIONS AND RELEVANCE

The findings suggest that higher county-level poverty concentration is associated with increased suicide rates among youths aged 5 to 19 years. These findings may guide research into upstream risk factors associated with pediatric suicide to inform suicide prevention efforts.

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.

Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit

OBJECTIVE

To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU).

STUDY DESIGN

Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital.

RESULTS

From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001).

CONCLUSION

The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.