Adolescent, Parent, and Provider Perceptions of a Predictive Algorithm to Identify Adolescent Suicide Risk in Primary Care

OBJECTIVE

To understand adolescent, parent, and provider perceptions of a machine learning algorithm for detecting adolescent suicide risk prior to its implementation primary care.

METHODS

We conducted semi-structured, qualitative interviews with adolescents (n = 9), parents (n = 12), and providers (n = 10; mixture of behavioral health and primary care providers) across two major health systems. Interviews were audio recorded and transcribed with analyses supported by use of NVivo. A codebook was developed combining codes derived inductively from interview transcripts and deductively from implementation science frameworks for content analysis.

RESULTS

Reactions to the algorithm were mixed. While many participants expressed privacy concerns, they believed the algorithm could be clinically useful for identifying adolescents at risk for suicide and facilitating follow-up. Parents' past experiences with their adolescents' suicidal thoughts and behaviors contributed to their openness to the algorithm. Results also aligned with several key Consolidated Framework for Implementation Research domains. For example, providers mentioned barriers inherent to the primary care setting such as time and resource constraints likely to impact algorithm implementation. Participants also cited a climate of mistrust of science and health care as potential barriers.

CONCLUSIONS

Findings shed light on factors that warrant consideration to promote successful implementation of suicide predictive algorithms in pediatric primary care. By attending to perspectives of potential end users prior to the development and testing of the algorithm, we can ensure that the risk prediction methods will be well-suited to the providers who would be interacting with them and the families who could benefit.

Development and evaluation of a writing retreat program to build community and promote productivity in academic hospital medicine

BACKGROUND

Scientific writing is a core component of academic hospital medicine, and yet finding time to engage in deeply focused writing is difficult in part due to the highly clinical, 24/7 nature of the specialty that can limit opportunities for writing-focused collaboration and mentorship.

OBJECTIVE

Our objective was to develop and evaluate an academic writing retreat program.

METHODS

We drafted a set of key retreat features to guide implementation of a 3-day, 2-night retreat program held within a 2 h radius of our hospital. Agendas included writing blocks ranging from 45 to 90 min interspersed with breaks and opportunities for feedback, exercise, and preparing meals together. After each retreat, we distributed an evaluation with multiple choice and free text response options to characterize retreat helpfulness and later gathered data on the status of each paper and grant worked on.

RESULTS

We held 4 retreats between September 2022 and October 2023, engaging 18 faculty and fellows at a cost of $296 per attendee per retreat. In evaluations, nearly 80% reported that the retreat was extremely helpful, and comments praised the highly mentored environment, enriching community of colleagues, and release from commitments that get in the way of writing. Of the 24 papers attendees worked on, 12 have been accepted and 6 are under review. Of the 4 grant proposals, 2 are under review.

CONCLUSIONS

We implemented a low-cost, productive writing retreat program that attendees reported was helpful in supporting deep work and represented a meaningful step toward building a community centered around academic writing.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Characteristics, disposition, and outcomes of children hospitalized for mental health boarding at a children's hospital

Increasingly, youth experiencing mental health crises present to acute care medical hospitals and "board" on medical units due to inpatient psychiatric bed shortages. We conducted a retrospective cohort study of children experiencing mental health boarding at a US children's hospital from October 2020 to September 2022. We examined associations between patients' characteristics and their disposition and outcomes. Our cohort included 1891 boarding hospitalizations: 53.9% transferred to an inpatient psychiatric hospital and 46.1% discharged home. Characteristics associated with not being transferred to an inpatient psychiatric hospital included age <13 years (adjusted odds ratio [aOR] 0.6; 95% confidence interval [CI]: 0.4-0.7), disruptive or aggressive behavior (aOR 0.6; 95% CI: 0.4-0.8), psychosis (aOR 0.5; 95% CI: 0.3-0.8), COVID-19 infection (aOR 0.3; 95% CI: 0.2-0.6), or a complex chronic medical condition (aOR 0.8; 95% CI: 0.6-1.0). Our findings suggest that certain populations of children experiencing mental health boarding face disparate access to inpatient psychiatric care.

Factors influencing agitation, de-escalation, and physical restraint at a children's hospital

BACKGROUND

Children hospitalized in medical hospitals are at risk of agitation. Physical restraint may be used to maintain patient and staff safety during de-escalation, but physical restraint use is associated with physical and psychological adverse events.

OBJECTIVE

We sought to better understand which work system factors help clinicians prevent patient agitation, improve de-escalation, and avoid physical restraint.

DESIGN, SETTING, AND PARTICIPANTS

We used directed content analysis to extend the Systems Engineering Initiative for Patient Safety model to clinicians working with children at risk for agitation at a freestanding children's hospital.

INTERVENTION, MAIN OUTCOME, AND MEASURES

We conducted semistructured interviews to examine how five clinician work system factors affected patient agitation, de-escalation, and restraint: person, environment, tasks, technology and tools, and organization. Interviews were recorded, transcribed, and analyzed until saturation.

RESULTS

Forty clinicians participated in this study, including 21 nurses, 15 psychiatric technicians, 2 pediatric physicians, 1 psychologist, and 1 behavior analyst. Work system factors that contributed to patient agitation were medical tasks like vital signs and the hospital environment including bright lights and neighboring patients' noises. Supports that helped clinicians de-escalate patients included adequate staffing and accessible toys and activities. Participants indicated that organizational factors were integral to team de-escalation, drawing connections between units' teamwork and communication cultures and their likelihood of successful de-escalation without the use of physical restraint.

CONCLUSION

Clinicians perceived that medical tasks, hospital environmental factors, clinician attributes, and team communication influenced patients' agitation, de-escalation, and physical restraint. These work system factors provide opportunities for future multi-disciplinary interventions to reduce physical restraint use.

"Treat Them Like a Human Being…They are Somebody's Somebody": Providers' Perspectives on Treating Patients in the Emergency Department After Self-Injurious Behavior

To understand ED providers' perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to "What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?" were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.

Nurse Education and Hospital Readmissions for Children With and Without a Mental Health Condition

OBJECTIVES

In adults, receiving care in a hospital with more baccalaureate-prepared nurses improves outcomes. This relationship is magnified in adults with serious mental illness or cognitive impairment. Whether the same is true in children with and without a mental health condition is unknown. The study purposes were to determine 1) whether the proportion of baccalaureate-prepared nurses affected the odds of readmission in children; and 2) whether this relationship differed for children with a mental health condition.

PATIENTS AND METHODS

We linked cross-sectional data from the 2016 Healthcare Cost and Utilization Project State Inpatient Databases, the RN4CAST-US nurse survey in Florida, and the American Hospital Association. Inclusion criteria were ages 3 to 21 years. Mental health conditions were defined as psychiatric or developmental/behavioral diagnoses. These were identified using the Child and Adolescent Mental Health Disorders Classification System. We used multivariable, hierarchical logistic regression models to assess the relationship between nurse training and readmissions.

RESULTS

In 35 081 patients admitted to 122 hospitals with 4440 nurses, 21.0% of patients had a mental health condition and 4.2% had a 7-day readmission. For individuals without a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 8.0% lower odds of readmission (odds ratio = 0.92, 95% confidence interval = 0.87-0.97). For those with a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 16.0% lower odds of readmission (odds ratio = 0.84, 95% confidence interval = 0.78-0.91).

CONCLUSIONS

A higher proportion of baccalaureate-educated nurses is associated with lower odds of readmission for pediatric patients. This association has a larger magnitude in patients with a mental health condition.

Acute medical workup for new-onset psychosis in children and adolescents: A retrospective cohort

No consensus exists about which medical testing is indicated for youth with new-onset psychotic symptoms. We conducted a chart review of youths aged 7-21 years who were medically hospitalized for workup of new-onset psychotic symptoms from January 2017 through September 2020 in a free-standing children's hospital. The sample included 131 patients. At discharge, 129 (98.5%; 95% confidence interval [CI]: 94.5-99.8) were diagnosed with a primary psychiatric condition, 1 was diagnosed with levetiracetam-induced psychosis, and 1 with seronegative autoimmune encephalitis. Notably, 33 (25.2%; 95% CI: 18.0-33.5) had incidental findings unrelated to psychosis, 14 (10.7%; 95% CI: 6.0-17.3) had findings that required medical intervention but did not explain the psychosis, 12 (9.2%; 95% CI: 4.8-15.5) had a positive urine drug screen, and 4 (3.1%; 95% CI: 0.8-7.6) had a neurological exam consistent with conversion disorder. In conclusion, extensive medical testing in the acute setting for psychosis had a low yield for identifying medical etiologies of new-onset psychotic symptoms.

Pediatric emergency departments' readiness for change toward improving suicide prevention: A mixed-methods study with US leaders

Objective

To assess pediatric emergency departments' (PEDs) current suicide prevention practices and climate for change to improve suicide prevention for youth.

Methods

We conducted an explanatory, sequential mixed-methods study. First, we deployed a national, cross-sectional survey of PED leaders identified through publicly available data in Fall 2020, and then we conducted follow-up interviews with those who expressed interest. The survey queried each PED's suicide prevention practices and measured readiness for change to improve suicide prevention practices using questions scored on a 5-point Likert scale. Interviews gathered further, in-depth descriptions of PEDs' practices and culture. Interviews were audio-recorded, transcribed verbatim, and analyzed using a rapid analysis approach.

Results

Of 135 PED directors eligible to complete the survey, 64 responded (response rate 47%). A total of 64% of PEDs had a mental health specialist available 24 hours/day, 7 days/week; 80% reported practicing mental health disposition planning, and 41% reported practicing psychiatric medication management. Altogether 91% of directors agreed or strongly agreed that their PED had a positive culture and 92% agreed/strongly agreed that their PED was ready for change. However, 31% disagreed/strongly disagreed that their PED had tools for evaluation and quality measurement. Resources needed for change (including budget, staffing, training, and facilities) varied across institutions. Interviews with our convenience sample of 21 directors revealed varying suicide prevention practices and confirmed that standardization, evaluation, and quality improvement initiatives were needed at most institutions. Leaders reported a high interest in improving care.

Conclusions

PED leaders reported high motivation to improve suicide prevention services for young people, and reported needing quality improvement infrastructure to monitor and guide improvement.

Mental Health and COVID-19 in Pediatric Emergency Departments: Perspectives From Directors

PURPOSE

The aim of this study is to understand pediatric emergency department (PED) directors' perspectives on the COVID-19 pandemic's effect on PED visits for mental health concerns.

METHODS

Semi-structured phone interviews were conducted with a national convenience sample of PED directors. Interviews were recorded, transcribed verbatim, and analyzed using rapid content analysis.

RESULTS

Twenty-one PED directors from 18 states were interviewed. Directors perceived an increased volume of mental health visits and higher patient acuity. Some PEDs innovatively adapted services but were also met with new barriers in providing care due to increased use of personal protective equipment and required COVID-19 testing. Transfer to inpatient psychiatric units was more complicated due to reduced overall bed capacity and the need for a negative COVID test.

DISCUSSION

The COVID-19 pandemic strained an already fragile pediatric emergency mental health system. Building infrastructure for adaptations and mental health service reserve capacity could help ensure proper care for pediatric patients with mental health crises during future public health emergencies.

Caregiver Experiences During Their Child’s Acute Medical Hospitalization for a Mental Health Crisis

Adolescents in the United States are increasingly seeking treatment for mental health crises in emergency departments and general medical hospitals. Medical needs are often addressed quickly, yet youth remain hospitalized because further psychiatric treatment is not immediately available. We sought to better understand the experiences of caregivers whose children are "boarding" in a medical hospital while awaiting inpatient psychiatric treatment. We conducted semi-structured interviews with caregivers who were recruited, enrolled, and interviewed during their child's hospital stay. Interviews were audio-recorded, transcribed verbatim, and thematic analysis was facilitated by NVivo 12. Fourteen caregivers enrolled in the study. Themes that emerged included positive hospital and provider experiences; frustration with the medical and mental health care systems; information needs; fears about inpatient psychiatric units; practical challenges and emotional needs; difficulties with caregiver-child communication; difficulties with clinician-caregiver communication; and need for self-care and support. While many caregivers felt positively about the overall experience at the hospital, they also wished for more information about their child's treatment plan and future, as well as social support, emotional comfort for themselves, and self-care skills and resources. Their experiences illuminate ways in which clinical practice can ameliorate concerns and alleviate stress of caregivers related to their child's mental health crisis.

Depression and Anxiety Symptoms During and After Pediatric Asthma Hospitalization

OBJECTIVES

Depression and anxiety are common in children with asthma, and asthma hospitalization is an underused opportunity to identify mental health concerns. We assessed depression and anxiety symptoms during asthma hospitalization and 1 to 2 months post discharge.

METHODS

This prospective cohort study included children aged 7 to 17 years who were hospitalized for asthma exacerbation. Participants completed the self-report PROMIS (Patient-Reported Outcomes Measurement Information System) depression and anxiety symptom scales (T score mean = 50, SD = 10) during hospitalization and 1 to 2 months after discharge. Higher scores indicate more symptoms and/or greater severity. We compared patients' scores during hospitalization and at follow-up using paired t tests and examined individual patients' depression and anxiety symptom trajectories using a Sankey diagram.

RESULTS

Among 96 participants who completed the study, 53% had elevated symptoms of depression, anxiety, or both either during hospitalization or after discharge. During hospitalization, 38% had elevated depression symptoms and 45% had elevated anxiety symptoms. At postdischarge follow-up, 18% had elevated depression symptoms and 20% had elevated anxiety symptoms. We observed all possible symptom trajectories: symptoms during hospitalization that persisted (especially if both depression and anxiety symptoms were present), symptoms that resolved, and symptoms that were present at follow-up only.

CONCLUSIONS

Just more than half of youth hospitalized for asthma exacerbation experienced depression and/or anxiety symptoms during hospitalization or at follow-up. Patients who had both depression and anxiety symptoms during hospitalization were the most likely to have persistent symptoms at follow-up. Screening at both time points may be useful to identify mental health symptoms.

Mental Health Service Use Before and After a Suicidal Crisis Among Children and Adolescents in a United States National Medicaid Sample

INTRODUCTION

Mental health follow-up after an emergency department (ED) visit for suicide ideation/attempt is a critical component of suicide prevention for young people.

METHODS

We analyzed 2009 to 2012 Medicaid Analytic EXtract for 62,139 treat-and-release ED visits and 30,312 ED-to-hospital admissions for suicide ideation/attempt among patients ages 6 to 17 years. We used mixed-effects logistic regression models to examine associations between patients' health care utilization prior to the ED visit and likelihood of completing a 30-day mental health follow-up visit.

RESULTS

Overall, for treat-and-release ED visits, 49% had a 30-day follow-up mental health visit, and for ED-to-hospital admissions, 67% had a 30-day follow-up mental health visit. Having a mental health visit in the 30 days preceding the ED visit was the strongest predictor of completing a mental health follow-up visit (ED treat-and-release: adjusted odds ratio [AOR] 11.01; 95% confidence interval [CI] 9.82-12.35; ED-to-hospital AOR 4.60; 95% CI 3.16-6.68). Among those with no mental health visit in the 30 days preceding the ED visit, only 25% had an ambulatory mental health follow-up visit. Having a general health care visit in the 30 days preceding the ED visit had a much smaller association with completing a mental health follow-up visit (ED treat-and-release: AOR 1.17; 95% CI 1.09-1.24; ED-to-hospital AOR 1.25; 95% CI 1.17-1.34).

CONCLUSIONS

Young people without an existing source of ambulatory mental health care have low rates of mental health follow-up after an ED visit for suicide ideation or attempt, and opportunities exist to improve mental health follow-up for youth with recent general health care visits.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit

BACKGROUND AND OBJECTIVES

To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns.

METHODS

We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day.

RESULTS

The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001).

CONCLUSIONS

Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

Trends in Length of Stay and Readmissions in Children's Hospitals

BACKGROUND AND OBJECTIVES

Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals.

METHODS

Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix.

RESULTS

Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased (P < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, P < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; P = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; P < .001).

CONCLUSIONS

Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

US Pediatric Emergency Department Visits for Mental Health Conditions During the COVID-19 Pandemic

This cross-sectional study describes the changes in the demographic characteristics and clinical outcomes of pediatric emergency department (ED) visits for mental health conditions during the COVID-19 pandemic.

Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity

OBJECTIVE

To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings.

STUDY DESIGN

Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC).

RESULTS

The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC.

CONCLUSION

Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).

Hospitalization Outcomes for Rural Children with Mental Health Conditions

OBJECTIVE

To identify where rural children with mental health conditions are hospitalized and to determine differences in outcomes based on location of hospitalization.

STUDY DESIGN

This is a retrospective cohort analysis of US rural children aged 0-18 years with a mental health hospitalization between January 1, 2014, and November 30, 2014, using the 2014 Agency for Healthcare Research and Quality's Nationwide Readmissions Database. Hospitalizations for rural children were categorized by children's hospitals, metropolitan non-children's hospitals, or rural hospitals. Associations between hospital location and outcomes were assessed with logistic (readmission) and negative binomial regression (length of stay [LOS]) models. Classification and regression trees (CART) were used to describe the characteristics of most common hospitalizations at a rural hospital.

RESULTS

Of 21 666 mental health hospitalizations of rural children, 20.6% were at rural hospitals. After adjustment for clinical and demographic characteristics, LOS was higher at metropolitan non-children's and children's hospitals compared with rural hospitals (LOS: adjusted rate ratio [aRR], 1.35 [95% CI 1.29-1.41] and 1.33 [95% CI, 1.25-1.41]; P < .01 for all). The 30-day readmission was lower at metropolitan non-children's and children's hospitals compared with rural hospitals (aOR, 0.73 [95% CI, 0.63-0.84] and 0.59 [95% CI, 0.48-0.71]; P < .001 for all). Adolescent males living in poverty with externalizing behavior disorder had the highest percentage of hospitalization at rural hospitals (69.4%).

CONCLUSIONS

Although hospitalizations at children's and metropolitan non-children's hospitals were longer, patient outcomes were more favorable.

Costs and Reimbursements for Mental Health Hospitalizations at Children's Hospitals

The financial impact of the rising number of pediatric mental health hospitalizations is unknown. Therefore, this study assessed costs, reimbursements, and net profits or losses for 111,705 mental health and non-mental health medical hospitalizations in children's hospitals with use of the Pediatric Health Information System and Revenue Management Program. Average financial margins were calculated as (reimbursement per day) - (cost per day), and they were lowest for mental health hospitalizations ($136/day), next lowest for suicide attempt ($518/day), and highest for other medical hospitalizations ($611/day). For 10 of 17 hospitals, margin per day for mental health hospitalizations was lower than margin per day for other medical hospitalizations. For these 10 hospitals, the total net loss for inpatient and observation status mental health hospitalizations, compared with other medical hospitalizations, was $27 million (median, $2.2 million per hospital). Financial margins were usually lower for mental health vs non-mental health medical hospitalizations.

Association of Suicide Prevention Interventions With Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systematic Review and Meta-analysis

Importance

To prevent suicide deaths, acute care settings need tools to ensure individuals at risk of suicide access mental health care and remain safe until they do so.

Objective

To examine the association of brief acute care suicide prevention interventions with patients' subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up.

Data Sources

Ovid MEDLINE, Scopus, CINAHL, PsychINFO, Embase, and references of included studies using concepts of suicide, prevention, and clinical trial to identify relevant articles published January 2000 to May 2019.

Study Selection

Studies describing clinical trials of single-encounter suicide prevention interventions were included. Two reviewers independently reviewed all articles to determine eligibility for study inclusion.

Data Extraction and Synthesis

Two reviewers independently abstracted data according to PRISMA guidelines and assessed studies' risk of bias using the Cochrane Risk of Bias tool. Data were pooled for each outcome using random-effects models. Small study effects including publication bias were assessed using Peter and Egger regression tests.

Main Outcomes and Measures

Three primary outcomes were examined: subsequent suicide attempts, linkage to follow-up care, and depression symptoms at follow-up. Suicide attempts and linkage to follow-up care were measured using validated patient self-report measures and medical record review; odds ratios and Hedges g standardized mean differences were pooled to estimate effect sizes. Depression symptoms were measured 2 to 3 months after the encounter using validated self-report measures, and pooled Hedges g standardized mean differences were used to estimate effect sizes.

Results

A total of 14 studies, representing outcomes for 4270 patients, were included. Pooled-effect estimates showed that brief suicide prevention interventions were associated with reduced subsequent suicide attempts (pooled odds ratio, 0.69; 95% CI, 0.53-0.89), increased linkage to follow-up (pooled odds ratio, 3.04; 95% CI, 1.79-5.17) but were not associated with reduced depression symptoms (Hedges g = 0.28 [95% CI, -0.02 to 0.59).

Conclusions and Relevance

In this meta-analysis, breif suicide prevention interventions were associated with reduced subsequent suicide attempts. Suicide prevention interventions delivered in a single in-person encounter may be effective at reducing subsequent suicide attempts and ensuring that patients engage in follow-up mental health care.

Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid

OBJECTIVE

To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.

METHODS

This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.

RESULTS

Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.

CONCLUSIONS

Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.

ED Visits and Readmissions After Follow-up for Mental Health Hospitalization

OBJECTIVES

A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition.

METHODS

We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome.

RESULTS

Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators.

CONCLUSIONS

Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.

Adolescents' Experiences During "Boarding" Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt

BACKGROUND

Two million adolescents experience suicidal ideation (SI) or suicide attempt (SA) annually, and they frequently present to emergency departments. Delays in transfer to inpatient psychiatric units increasingly lead to "boarding" in emergency departments and inpatient medical units. We sought to understand adolescents' perspectives during boarding hospitalizations to gain insight into helpful practices and targets for improvement.

METHODS

Using convenience sampling, we conducted semistructured interviews with 27 adolescents hospitalized for SI or SA while they were awaiting transfer to an inpatient psychiatric facility. Interviews were recorded and transcribed, and the thematic analysis was organized using NVivo 11.

RESULTS

Eight themes emerged: (1) supportive clinical interactions, (2) information needs, (3) repetitive inquiries, (4) safety, (5) previous hospital experiences, (6) activities and boredom, (7) physical comfort, and (8) emotions. Adolescents expressed appreciation for compassionate clinicians and for receiving information about what to expect, experienced the hospital as a safe environment, emphasized the value of staying occupied and of physical comfort, and were relieved to be receiving help to reduce their suicidal thoughts or behaviors. Reports of embarrassment and discomfort about repeated inquiries from the clinical team, comparisons with previous hospital experiences, and unanswered questions about what would occur during the planned inpatient psychiatric hospitalization were common.

CONCLUSIONS

The perspectives of adolescents seeking care for SI or SA are an important source of information for health care systems seeking to improve hospital care. Clinicians can relieve distress of adolescents awaiting psychiatric hospitalization by focusing on compassionate connection, minimizing repeated inquiries, and providing complete and concrete information about treatment plans.

Outpatient Prescription Opioid Use in Pediatric Medicaid Enrollees With Special Health Care Needs

BACKGROUND AND OBJECTIVES

Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN.

METHODS

This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with ≥1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE.

RESULTS

Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions (≥3 conditions: 49.1% vs 30.6%), and had more polypharmacy (≥5 other medication classes: 54.7% vs 31.2%), P < .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively.

CONCLUSIONS

OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up.

Association of Extending Hospital Length of Stay With Reduced Pediatric Hospital Readmissions

This cohort study explores the association between index hospitalization length of stay and hospital readmissions among 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.

Mental Health Conditions and Unplanned Hospital Readmissions in Children

OBJECTIVE

Mental health conditions (MHCs) are prevalent among hospitalized children and could influence the success of hospital discharge. We assessed the relationship between MHCs and 30-day readmissions.

METHODS

This retrospective, cross-sectional study of the 2013 Nationwide Readmissions Database included 512,997 hospitalizations of patients ages 3 to 21 years for the 10 medical and 10 procedure conditions with the highest number of 30-day readmissions. MHCs were identified by using the International Classification of Diseases, 9th Revision-Clinical Modification codes. We derived logistic regression models to measure the associations between MHC and 30-day, all-cause, unplanned readmissions, adjusting for demographic, clinical, and hospital characteristics.

RESULTS

An MHC was present in 17.5% of medical and 13.1% of procedure index hospitalizations. Readmission rates were 17.0% and 6.2% for medical and procedure hospitalizations, respectively. In the multivariable analysis, compared with hospitalizations with no MHC, hospitalizations with MHCs had higher odds of readmission for medical admissions (adjusted odds ratio [AOR], 1.23; 95% confidence interval [CI], 1.19-1.26] and procedure admissions (AOR, 1.24; 95% CI, 1.15-1.33). Three types of MHCs were associated with higher odds of readmission for both medical and procedure hospitalizations: depression (medical AOR, 1.57; 95% CI, 1.49-1.66; procedure AOR, 1.39; 95% CI, 1.17-1.65), substance abuse (medical AOR, 1.24; 95% CI, 1.18-1.30; procedure AOR, 1.26; 95% CI, 1.11-1.43), and multiple MHCs (medical AOR, 1.43; 95% CI, 1.37-1.50; procedure AOR, 1.26; 95% CI, 1.11-1.44).

CONCLUSIONS

MHCs are associated with a higher likelihood of hospital readmission in children admitted for medical conditions and procedures. Understanding the influence of MHCs on readmissions could guide strategic planning to reduce unplanned readmissions for children with cooccurring physical and mental health conditions.

Parent Coping Support Interventions During Acute Pediatric Hospitalizations: A Meta-Analysis

CONTEXT

Parents may experience psychological distress when a child is acutely hospitalized, which can negatively affect child outcomes. Interventions designed to support parents' coping have the potential to mitigate this distress.

OBJECTIVE

To describe interventions designed to provide coping support to parents of hospitalized children and conduct a meta-analysis of coping support intervention outcomes (parent anxiety, depression, and stress).

DATA SOURCES

We searched Pubmed, Embase, PsycINFO, Psychiatry Online, and Cumulative Index to Nursing and Allied Health Literature from 1985 to 2016 for English-language articles including the concepts "pediatric," "hospitalization," "parents," and "coping support intervention."

STUDY SELECTION

Two authors reviewed titles and abstracts to identify studies meeting inclusion criteria and reviewed full text if a determination was not possible using the title and abstract. References of studies meeting inclusion criteria were reviewed to identify additional articles for inclusion.

DATA EXTRACTION

Two authors abstracted data and assessed risk of bias by using a structured instrument.

RESULTS

Initial searches yielded 3450 abstracts for possible inclusion. Thirty-two studies met criteria for inclusion in the systematic review and 12 studies met criteria for inclusion in the meta-analysis. The most commonly measured outcomes were parent depression, anxiety, and stress symptoms. In meta-analysis, combined intervention effects significantly reduced parent anxiety and stress but not depression. Heterogeneity among included studies was high.

LIMITATIONS

Most included studies were conducted at single centers with small sample sizes.

CONCLUSIONS

Coping support interventions can alleviate parents' psychological distress during children's hospitalization. More evidence is needed to determine if such interventions benefit children.

Mental Health Conditions and Symptoms in Pediatric Hospitalizations: A Single-Center Point Prevalence Study

BACKGROUND

Children and adolescents necessitating hospitalization for physical health conditions are at high risk for mental health conditions; however, the prevalence of mental health conditions and symptoms among hospitalized children and adolescents is uncertain. The objective of this study was to determine the proportion of hospitalized children and adolescents who have diagnosed mental health disorders or undiagnosed mental health problems.

METHODS

In this single-center point prevalence study of hospitalized children between the ages of 4 and 21 years, patients or their parents reported known mental health diagnoses and use of services using the Services Assessment for Children and Adolescent, and they reported patient mental health symptoms using the Pediatric Symptom Checklist, 17-item form (PSC-17).

RESULTS

Of 229 eligible patients, 119 agreed to participate. Demographic characteristics of patients who enrolled were not statistically significantly different from those of patients who declined to participate. Among participants, 26% (95% confidence interval [CI], 18%-35%) reported a known mental health diagnosis. On the PSC-17, 29% (95% CI, 21%-38%) of participants had a positive screen for mental health symptoms. Of those with a positive screen, 38% (95% CI, 21%-55%) had no known mental health diagnosis, and 26% (95% CI, 12%-43%) had not received ambulatory mental health services in the 12 months before hospitalization.

CONCLUSIONS

Mental health conditions and symptoms are common among patients hospitalized in a tertiary children's hospital, and many affected patients are not receiving ambulatory mental health services.

Family Report Compared to Clinician-Documented Diagnoses for Psychiatric Conditions Among Hospitalized Children

BACKGROUND

Psychiatric comorbidity is common in pediatric medical and surgical hospitalizations and is associated with worse hospital outcomes. Integrating medical or surgical and psychiatric hospital care depends on accurate estimates of which hospitalized children have psychiatric comorbidity.

OBJECTIVE

We conducted a study to determine agreement of family report (FR) and clinician documentation (CD) identification of psychiatric diagnoses in hospitalized children.

DESIGN AND SETTING

This was a cross-sectional study at a tertiary-care children's hospital.

PATIENTS

The patients were children and adolescents (age, 4-21 years) who were hospitalized for medical or surgical indications.

MEASUREMENTS

Psychiatric diagnoses were identified from structured interviews (FR) and from inpatient notes and International Classification of Diseases codes in medical records (CD). We compared estimates of point prevalence of any comorbid psychiatric diagnosis using each method, and estimated FR--CD agreement in identifying psychiatric comorbidity in hospitalized children.

RESULTS

Of 119 study patients, 26 (22%; 95% confidence interval [CI], 14%-29%) had a psychiatric comorbidity identified by FR, 30 (25%; 95% CI, 17%-34%) had it identified by CD, and 37 (23%-40%) had it identified by FR or CD. Agreement between FR and CD was low overall (κ = .46; 95% CI, .27-.66), highest for attention-deficit/hyperactivity disorder (κ = .78; 95% CI, .59-.97), and lowest for anxiety disorders (κ = .11; 95% CI, -.16 to .56).

CONCLUSIONS

Current methods may underestimate the prevalence of psychiatric conditions in hospitalized children. Information from multiple sources may be needed to develop accurate estimates of the scope of the population in need of services so that mental health resources can be appropriately allocated. Journal of Hospital Medicine 2017;12.

Validity and Reliability of a Tool to Assess Quality Improvement Knowledge and Skills in Pediatrics Residents

BACKGROUND

Residency programs are expected to educate residents in quality improvement (QI). Effective assessments are needed to ensure residents gain QI knowledge and skills. Limitations of current tools include poor interrater reliability and requirement for scorer training.

OBJECTIVE

To provide evidence for the validity of the Assessment of Quality Improvement Knowledge and Skills (AQIKS), which is a new tool that provides a summative assessment of pediatrics residents' ability to recall QI concepts and apply them to a clinical scenario.

METHODS

We conducted a quasi-experimental study to measure the AQIKS performance in 2 groups of pediatrics residents: postgraduate year (PGY) 2 residents who participated in a 1-year longitudinal QI curriculum, and a concurrent control group of PGY-1 residents who received no formal QI training. The curriculum included 20 hours of didactics and participation in a resident-led QI project. Three faculty members with clinical QI experience, who were not involved in the curriculum and received no additional training, scored the AQIKS.

RESULTS

Complete data were obtained for 30 of 37 residents (81%) in the intervention group, and 36 of 40 residents (90%) in the control group. After completing a QI curriculum, the intervention group's mean score was 40% higher than at baseline (P < .001), while the control group showed no improvement (P = .29). Interrater reliability was substantial (κ = 0.74).

CONCLUSIONS

The AQIKS detects an increase in QI knowledge and skills among pediatrics residents who participated in a QI curriculum, with better interrater reliability than currently available assessment tools.

Mental Health Conditions and Medical and Surgical Hospital Utilization

OBJECTIVE

Mental health conditions are prevalent among children hospitalized for medical conditions and surgical procedures, but little is known about their influence on hospital resource use. The objectives of this study were to examine how hospitalization characteristics vary by presence of a comorbid mental health condition and estimate the association of a comorbid mental health condition with hospital length of stay (LOS) and costs.

METHODS

Using the 2012 Kids' Inpatient Database, we conducted a retrospective, nationally representative, cross-sectional study of 670 161 hospitalizations for 10 common medical and 10 common surgical conditions among 3- to 20-year-old patients. Associations between mental health conditions and hospital LOS were examined using adjusted generalized linear models. Costs of additional hospital days associated with mental health conditions were estimated using hospital cost-to-charge ratios.

RESULTS

A comorbid mental health condition was present in 13.2% of hospitalizations. A comorbid mental health condition was associated with a LOS increase of 8.8% (from 2.5 to 2.7 days, P < .001) for medical hospitalizations and a 16.9% increase (from 3.6 to 4.2 days, P < .001) for surgical hospitalizations. For hospitalizations in this sample, comorbid mental health conditions were associated with an additional 31 729 (95% confidence interval: 29 085 to 33 492) hospital days and $90 million (95% confidence interval: $81 to $101 million) in hospital costs.

CONCLUSIONS

Medical and surgical hospitalizations with comorbid mental health conditions were associated with longer hospital stay and higher hospital costs. Knowledge about the influence of mental health conditions on pediatric hospital utilization can inform clinical innovation and case-mix adjustment.

The Influence of Comorbid Mood and Anxiety Disorders on Outcomes of Pediatric Patients Hospitalized for Pneumonia

OBJECTIVES

Mood and anxiety disorders are associated with greater inpatient care utilization in children with chronic illness. We sought to investigate the association of mood or anxiety disorders and outcomes for hospitalized pediatric patients, using pneumonia as a model.

METHODS

We conducted a retrospective, cross-sectional study of pneumonia hospitalizations in patients 5 to 20 years old, using the nationally representative Healthcare Cost and Utilization Project's 2012 Kids' Inpatient Database. We used multivariable logistic and linear regression models stratified by age group to determine the independent association of mood or anxiety disorders with complications and length of stay, adjusted for clinical, demographic, and hospital characteristics.

RESULTS

Of 34,794 pneumonia hospitalizations, 3.5% involved a patient with a comorbid mood or anxiety disorder. Overall incidence of complications was 13.1%. Mean length of stay was 4.5 days. In adjusted models, comorbid mood or anxiety disorders were associated with greater odds of pneumonia complications in school-aged children (odds ratio 1.80; 95% confidence interval, 1.20-2.71) and adolescents (odds ratio 1.63; 95% confidence interval, 1.31-2.02). Hospitalizations with an associated mood or anxiety disorder were longer than those without, by 11.2% in school-aged children and 13.6% in adolescents (P < .001). The association of mood and anxiety disorders with longer hospital stay was not modified by the presence of pneumonia complications.

CONCLUSIONS

In pediatric patients hospitalized for pneumonia, a comorbid mood or anxiety disorder is associated with greater odds of complications and longer hospital stay. The presence of pneumonia complications did not influence the relationship between mood or anxiety disorders and length of stay.