Clare Gray

The HEADS-ED: A Rapid Mental Health Screening Tool for Pediatric Patients in the Emergency Department

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics called for action for improved screening of mental health issues in the emergency department (ED). We developed the rapid screening tool home, education, activities/peers, drugs/alcohol, suicidality, emotions/behavior, discharge resources (HEADS-ED), which is a modification of “HEADS,” a mnemonic widely used to obtain a psychosocial history in adolescents. The reliability and validity of the tool and its potential for use as a screening measure are presented. METHODS: ED patients presenting with mental health concerns from March 1 to May 30, 2011 were included. Crisis intervention workers completed the HEADS-ED and the Child and Adolescent Needs and Strengths-Mental Health tool (CANS MH) and patients completed the Children’s Depression Inventory (CDI). Interrater reliability was assessed by using a second HEADS-ED rater for 20% of the sample. RESULTS: A total of 313 patients were included, mean age was 14.3 (SD 2.63), and there were 182 females (58.1%). Interrater reliability was 0.785 (P < .001). Correlations were computed for each HEADS-ED category and items from the CANS MH and the CDI. Correlations ranged from r = 0.17, P < .05 to r = 0.89, P < .000. The HEADS-ED also predicted psychiatric consult and admission to inpatient psychiatry (sensitivity of 82% and a specificity of 87%; area under the receiver operator characteristic curve of 0.82, P < .01). CONCLUSIONS: The results provide evidence to support the psychometric properties of the HEADS-ED. The study shows promising results for use in ED decision-making for pediatric patients with mental health concerns.

Establishing best practice in pediatric emergency mental health: a prospective study examining clinical characteristics.

Objectives: The objectives of this prospective study were to determine the demographic and clinical characteristics of children and youth presenting to the emergency department (ED) for mental health concerns through the use of a valid standardized assessment protocol. Methods: Children and adolescents, 8 to 17 years, who presented to an ED-based crisis intervention program during fiscal years 2005 to 2006, completed self-report measures of depression, anxiety, and behavior. Clinicians completed the childhood acuity of psychiatric illness based on their assessment. Results: The clinician ratings indicated that 93.1% of the sample had at least 1 risk behavior or clinical symptom in the moderate/severe range. Admittance rate for the sample was 17.9% (low-risk admissions, 5.8%; high-risk deflections, 9%). Significant differences were found in presentations by sex and age as follows: (1) female youths (12-17 years) were more likely than male youth to report clinically significant depressive symptoms and to present with suicidal ideation/gesture and self-injury. (2) Male youths (12-17 years) were more likely to present with aggression to people/objects than female youth. (3) Male children younger than 12 years were more likely to present with high activity level than female children. Self-report measures (depression, anxiety, and behavior) corelated with corresponding clinician ratings. Conclusions: This research, through the use of a multi-informant standardized assessment protocol, presents a comprehensive study of children and youth presenting to the ED with mental health issues. Identifying the clinical characteristics of this population is an important first step toward establishing best practice within an ED.

Physician management of pediatric mental health patients in the emergency department: assessment, charting, and disposition

Objective The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. Methods A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. Results The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. Conclusions This study revealed that the pediatric emergentologists’ charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients.

Evaluating crisis intervention services for youth within an emergency department : a view from within

An innovative crisis intervention programme was created at the Childrens Hospital of Eastern Ontario in Canada in order to provide emergency assessments for youth presenting with mental health crises. The current investigation presents an overview of the programme and examines the emergency staffs perception and satisfaction with it. Eighty-seven emergency department medical staff completed a survey. Overall, emergency department staff place high value on having access to emergency mental health services, are pleased with the quality of service and appreciate that the crisis intervention workers presence allows them to spend more time with other patients.

Child and Adolescent Mental Health Repeat Visits to the Emergency Department: A Systematic Review

OBJECTIVES Repeat visits represent up to 45% of mental health (MH) presentations to emergency departments (EDs) and are associated with higher health care costs. We aimed to synthesize available literature on predictors of pediatric MH repeat ED visits and differences between repeat visitors and nonrepeat visitors. METHODS A systematic review was performed using PsycINFO, PubMed, and CINAHL databases. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist. Methodologic quality was assessed using the following 8 criteria: design, generalizability, breadth of predictors, reporting of effect sizes, additional outcomes, interaction terms, confounding variables, and clear definition of repeat visits. RESULTS A total of 178 articles were retrieved; 11 articles met inclusion criteria. Quality assessment revealed that all studies used chart review or administrative data. Predictors were grouped into 3 categories: demographic, clinical, and MH care access and utilization factors. Common predictors associated with repeat ED MH visits included socioeconomic status, involvement with child protective services, and previous and current MH service use. For studies using a 6-month repeat window, the most common factors were previous psychiatric hospitalization and currently receiving MH services. Heterogeneity in statistical analyses and determinants explored precluded the use of meta-analysis. CONCLUSIONS Findings revealed that repeat visits to the ED for MH concerns is a complex phenomenon that can be attributed to various demographic, clinical, and MH care access and utilization factors. To further elucidate the strongest predictors, future prospective research should consider prospective designs and include family factors. Investigating recency and frequency outcomes can also inform clinical practice.

Predictors of Repeated Visits to a Pediatric Emergency Department Crisis Intervention Program.

OBJECTIVES Despite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits. METHODS We examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression. RESULTS A total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances. CONCLUSIONS Repeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.

Evaluating mental health service use during and after emergency department visits in a multisite cohort of Canadian children and youth

OBJECTIVES The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed. METHODS A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fishers exact test to compare sites. RESULTS The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed. CONCLUSIONS Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.

An Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions

Children and youth presenting to the emergency department with mental health concerns present a challenge for clinicians and system capacity. Addressing a significant system gap and sparse strategies in the literature, representative leaders from hospital and community agencies developed a novel pathway to guide efficient and doable risk assessment and ensure timely transition to appropriate community mental health services. This article describes and reflects on our innovative Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions that bridges traditional barriers between hospital and community settings to address mental health needs for this population.