Flood of pediatric mental health patients strains emergency department resources

Steven C. Rogers; Thomas H. Chun

doi:10.1542/aapnews.2014356-1a

Over the last decade, there has been a concerning rise in emergency department (ED) visits for mental health concerns. Pediatric patients are being referred to the ED by mental health providers, schools and pediatricians, and many are brought by family members.

Between the late 1990s and last year, such visits to the Connecticut Children’s Medical Center ED skyrocketed from 400 to 2,500 annual visits. This increase mirrors national trends and has resulted in more than 500,000 annual visits to EDs for pediatric psychiatric problems (Pittsenbarger ZE, Mannix R. Acad Emerg Med. 2014;21:25-30).

Many EDs already are straining to deal with issues involving capacity and limited resources while still providing high-quality care for all patients. This burgeoning mental health crisis has significant implications for all those involved, including mental health patients, other patients and ED care providers.

For patients seeking emergent mental health care, there may be long waits for risk evaluation and even longer boarding in the ED for those requiring inpatient services. To ensure the safety of these potentially high-risk patients, they often are triaged at the highest acuity level and given priority for evaluation rooms. At times, mental health patients can outnumber typical ED patients. As a result, patients seeking emergent medical care may face prolonged wait times, increasing rates of leaving without being seen.

Dr. Rogers

Finally, health professionals who care for high-risk mental health patients face increased levels of stress. Providers and staff struggle with more difficult triage decisions, increased staffing demands to provide direct observation of patients, and insufficient psychiatric training to handle the prolonged care of mental health patients in crisis.

Dr. Chun

Responding to this crisis

An estimated 70% of patients cared for in EDs will screen positive for at least one mental health disorder. Most individuals who commit suicide have seen a health care professional within a few months of killing themselves. Every ED visit may be an opportunity to screen and identify high-risk patients and to intervene early, which ultimately may prevent future ED visits.

Following are recommendations on how EDs can balance the needs of mental health patients with those of other patients and staff:

Ensure the ED has appropriate support and levels of care.
- EDs should have well-defined processes and services to ensure adequate mental health care.
- Utilize all available resources, including social work and administrative support.
- Develop plans to ensure the safety and efficient risk assessment with disposition planning.
- Identify partnerships with local and state agencies to provide appropriate outpatient care.
Improve screening/care models to identify and provide appropriate resources before they require emergency care.
Dedicate more time in pediatric residency and fellowship curriculums to ensure adequate understanding of mental health risk assessment and appropriate care provision for mental health patients.
Advocate at the local, state and national levels with a focus on the actions recommended in the 2006 AAP policy statement, Pediatric Mental Health Emergencies in the Emergency Medical Services System, http://pediatrics.aappublications.org/content/118/4/1764.full.pdf.

Resources for ED professionals

Following are some resources to help health care professionals working in EDs manage pediatric patients with mental health concerns:

The 2011 AAP technical report Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System, developed by the Committee on Pediatric Emergency Medicine, describes the role of the ED provider in mental health care for U.S. children and adolescents, http://pediatrics.aappublications.org/content/127/5/e1356.full. The committee is developing a new AAP clinical report regarding pediatric mental health emergencies.
The American Academy of Child and Adolescent Psychiatry website provides resources as well as a way to identify local child and adolescent psychiatrists, www.aacap.org/AACAP/Families_and_Youth/Resources/CAP_Finder.aspx.
The Suicide Prevention Research Center (www.sprc.org) and the National Suicide Prevention Lifeline (www.suicidepreventionlifeline.org) provide resources on suicide prevention, including a registry of evidence-based practices.
The Substance Abuse and Mental Health Services Administration provides a regional treatment locator, www.findtreatment.samhsa.gov/MHTreatmentLocator.
Massachusetts Child Psychiatry Access Project (http://www.mcpap.com/) describes a successful model for mental health patients in schools and primary care settings, which may increase utilization of community resources and ultimately reduce ED visits.
Resources for gay, lesbian, bisexual and transgender youth:
- The Trevor Project (www.thetrevorproject.org) provides suicide prevention and crisis intervention.
- GLBT National Youth Talkline (www.glnh.org/talkline) provides telephone and email peer-counseling, as well as factual information and local resources.

Footnotes

Dr. Rogers is chair of the AAP Section on Emergency Medicine Committee for the Future. Dr. Chun is a member of the AAP Committee on Pediatric Emergency Medicine.