Jacqueline Grupp-Phelan

Trends in mental health and chronic condition visits by children presenting for care at U.S. emergency departments.

Objective. The purpose of this study was to compare the burden of mental health disorders to the burden of other chronic care conditions as measured by emergency department (ED) visits by children with respect to prevalence rates, time trends, and hospital admission rates. Methods. Data from the 1995–2001 National Hospital Ambulatory Medical Care Survey were used to assess the number of visits to emergency departments by children with a diagnosis of a mental health or chronic condition, a mental health-related reason for the visit, or a prescription or continuation of psychotropic medication. Results. From 1995 to 2001, there was an increase in the proportion of visits by children with mental health problems. During the same period, the proportion of visits by children with chronic illness appeared stable. Overall, mental health diagnoses made up approximately 5% of all U.S. emergency department visits by children, similar to the percentage of total visits for other chronic conditions (5.2%). Approximately 15% of visits in both the mental health and chronic condition groups ended in hospital admission compared to less than 5% in the overall group of ED visits by children. Conclusions. The burden of mental health related visits to U.S. EDs is growing at a faster rate than visits related to chronic conditions. Visit intensity, hospital admission, and medication utilization is just as intense as that for chronic conditions. Promoting provider mental health training and restructuring the ED visit to allow for rapid mental health assessment and immediate onsite or contiguous mental health care may be one way to improve outcomes for families and to position the ED as part of a larger integrated system of effective mental illness care.

Identifying Children with Pneumonia in the Emergency Department

Emergency physicians need to clinically differentiate children with and without radiographic evidence of pneumonia. In this prospective cohort study of 510 patients 2 to 59 months of age presenting with symptoms of lower respiratory tract infection, 100% were evaluated with chest radiography and 44 (8.6%) had pneumonia on chest radiography. With use of multivariate analysis, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) of the clinical findings significantly associated with focal infiltrates were age older than 12 months (AOR 1.4, CI 1.1-1.9), RR 50 or greater (AOR 3.5, CI 1.6-7.5), oxygen saturation 96% or less (AOR 4.6, CI 2.3-9.2), and nasal flaring (AOR 2.2 CI 1.2-4.0) in patients 12 months of age or younger. The combination of age older than 12 months, RR 50 or greater, oxygen saturation 96% or less, and in children under age 12 months, nasal flaring, can be used in determining which young children with lower respiratory tract infection symptoms have radiographic pneumonia.

Children's mental health emergencies-part 1: Challenges in care: Definition of the problem, barriers to care, screening, advocacy, and resources

Objective: At a time when there has been a reduction in mental health resources nationwide, the incidence of mental health disorders in children has seen a dramatic increase for many reasons. Methods: A review of the literature was done to identify the epidemiology, barriers to care, useful emergency department (ED) screening methods, and resources regarding pediatric mental health disorders in the ED. Results: Although there are many challenges to the provision of care for children with mental health emergencies, some resources are available. Furthermore, ED screening and intervention may be effective in improving patient outcomes. Conclusions: Collaborative efforts with multidisciplinary services can create a continuum of care, promote better identification of children and adolescents with mental health disorders, and promote early recognition and intervention, which are key to effective referral and treatment.

Failure of psychiatric referrals from the pediatric emergency department

BackgroundRecognition of mental illness in the pediatric emergency department (PED) followed by brief, problem oriented interventions may improve health-care seeking behavior and quality of life. The objective of this study was to compare the frequency of mental health follow up after an enhanced referral compared to a simple referral in children presenting to the PED with unrecognized mental health problems.MethodsA prospective randomized control trial comparing an enhanced referral vs. simple referral in 56 families of children who were screened for mental health symptoms was performed in a large tertiary care PED. Children presenting to the PED with stable medical problems were approached every fourth evening for enrollment. After consent/assent was obtained, children were screened for a mental health problem using both child and parent reports of the DISC Predictive Scales. Those meeting cutoffs for a mental health problem by either parent or child report were randomized to 1) simple referral (phone number for mental health evaluation by study psychiatrist) or 2) enhanced referral (short informational interview, appointment made for child, reminder 2 days before and day of interview for an evaluation by study psychiatrist). Data analysis included descriptive statistics and Chi-Square test to calculate the proportion of children with mental health problems who completed mental health follow-up with and without the enhanced referral.ResultsA total of 69 families were enrolled. Overall 56 (81%) children screened positive for a mental health problem as reported by either the child (self report) or mother (maternal report of child mental health problem). Of these, 33 children were randomized into the enhanced referral arm and 23 into the simple referral arm. Overall, only 6 families with children screening positive for a mental health problem completed the psychiatric follow up evaluation, 2 in the enhanced referral arm and 4 in the simple referral arm (p = .13).ConclusionChildren screened in the ED for unrecognized mental health problems are very unlikely to follow-up for a mental health evaluation with or without an enhanced referral. Understanding the role of ED based mental health screening and the timing of an intervention is key in developing ED based mental health interventions.

Using Natural Language Processing to Classify Suicide Notes

We hypothesize that machine-learning algorithms (MLA) could classify completer and ideator suicide notes as well a mental health professionals (MHP). Five MHPs classified 66 notes as either ideator or completer; machine learning algorithms (MLA) were used for the same task. Results: MHPs were accurate 71% of the time; the SMO algorithm was accurate 79% of the time. This is an important first step in developing an evidence based suicide predictor for emergency department use. Language: en

Referral to the Emergency Department by a Primary Care Provider Predicts Severity of Illness

OBJECTIVE: The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization. METHODS: A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed. RESULTS: A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus. CONCLUSIONS: Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.

Mental Health Follow-Up among Adolescents with Suicidal Behaviors after Emergency Department Discharge

The objective of this study was to examine mental health follow-up patterns and need for additional urgent ED evaluation in adolescents discharged home from a pediatric ED after an evaluation for suicidal ideation or attempt. In the study, the parent or guardian of suicidal youth ages 11 to 18 years who were discharged from the pediatric ED were interviewed by telephone between 1 and 2 months following the initial visit and asked about their childs suicide risk, mental health follow-up, return ED visits, and previous mental health experiences. ED records were also examined for return visits. A parent or guardian of 100 suicidal adolescents was interviewed by telephone. Most (66%) successfully followed up with a mental health provider. Mental health follow-up was more likely in those with an existing psychiatric diagnosis (OR: 3.03 [95% CI: 1.02–9.05]). The majority of those that returned to the ED within 2 months of their initial evaluation for mental health reasons were admitted [92% (19/21)]. The odds of an ED return visit were increased by a prior inpatient psychiatric admission (OR: 5.23 [95% CI: 1.80–15.16]), and a suicide attempt immediately prior to the initial ED visit (OR: 4.87 [95% CI: 1.04–22.69]). Many suicidal youth who are discharged from the ED successfully follow up with an outpatient mental health provider. However, a significant number do return to the ED within 2 months and require inpatient psychiatric admission. Future ED based interventions should focus on adolescents who attempt suicide and those with a history of prior inpatient admission.

A randomized controlled trial to engage in care of adolescent emergency department patients with mental health problems that increase suicide risk.

Background In pediatric emergency departments (EDs), adolescents at risk for suicide often escape detection and successful referral for outpatient mental health care. Objective This study aimed to assess the effectiveness of a brief, ED-based mental health service engagement intervention to increase linkage to outpatient mental health services. Design/Methods Adolescents presenting to a pediatric ED who were not currently receiving mental health services were screened for suicide-related risk factors (Columbia Suicide Scale). If positive, youths were then screened for impairment, alcohol use, and depression. Those screening positive on the Columbia Suicide Scale and the alcohol, impairment, or depression screen were randomly assigned to the intervention (short motivational interview, barrier reduction, outpatient appointment established, reminders before scheduled appointment) or standard referral (telephone number for a mental health provider). Study groups were compared with respect to screen acceptability and outpatient mental health care linkage and change in depression symptoms at 60 days after the index ED visit. Results A total of 204 families were enrolled. Overall, 24 adolescents (12%) screened positive for suicide risk factors and were randomized to the intervention (n = 11) or standard referral (n = 13) groups. The groups did not significantly differ on several measures of screen acceptability. As compared with the standard referral group (15.4%), the intervention group (63.6%) was significantly more likely to attend a mental health appointment during the follow-up period (Fisher exact test, P = 0.03). There was also a nonsignificant trend toward greater improvement of depressive symptoms in the intervention than standard referral group (t = 1.79, df = 18, P = 0.09). Conclusions When adolescents are identified in the ED with previously unrecognized mental health problems that increase suicide risk, a brief motivational and barrier-reducing intervention improves linkage to outpatient mental health services.

Comparison of Emergency Care Delivered to Children and Young Adults With Complex Chronic Conditions Between Pediatric and General Emergency Departments

OBJECTIVES Increasing attention is being paid to medically complex children and young adults, such as those with complex chronic conditions, because they are high consumers of inpatient hospital days and resources. However, little is known about where these children and young adults with complex chronic conditions seek emergency care and if the type of emergency department (ED) influences the likelihood of admission. The authors sought to generate nationwide estimates for ED use by children and young adults with complex chronic conditions and to evaluate if being of the age for transition to adult care significantly affects the site of care and likelihood of hospital admission. METHODS This was a cross-sectional study using discharge data from the 2008 Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality to evaluate visits to either pediatric or general EDs by pediatric-aged patients (17 years old or younger) and transition-aged patients (18 to 24 years old) with at least one complex chronic condition. The main outcome measures were hospital admission, ED charges for treat-and-release visits, and total charges for admitted patients. RESULTS In 2008, 69% of visits by pediatric-aged and 92% of visits by transition-aged patients with multiple complex chronic conditions occurred in general EDs. Not surprisingly, pediatric age was the strongest predictor of seeking care in a pediatric ED (odds ratio [OR] = 15.86; 95% confidence interval [CI] = 12.3 to 20.5). Technology dependence (OR = 1.56; 95% CI =1.2 to 2.0) and presence of multiple complex chronic conditions (OR = 1.39; 95% CI = 1.2 to 1.6) were also associated with higher odds of seeking care in a pediatric ED. When controlling for patient and hospital characteristics, type of ED was not a significant predictor of admission (p = 0.87) or total charges (p = 0.26) in either age group. CONCLUSIONS Overall, this study shows that, despite their complexity, the vast majority of children and young adults with multiple complex chronic conditions are cared for in general EDs. When controlling for patient and hospital characteristics, the admission rate and total charges for hospitalized patients did not differ between pediatric and general EDs. This result highlights the need for increased attention to the care that these medically complex children and young adults receive outside of pediatric-specialty centers. These results also emphasize that any future performance metrics developed to evaluate the quality of emergency care for children and young adults with complex chronic conditions must be applicable to both pediatric and general ED settings.

Assessment of disparities in the use of anxiolysis and sedation among children undergoing laceration repair.

OBJECTIVE The aim of this study was to determine if race/ethnicity and socioeconomic status (SES) were associated with the provision of anxiolysis and/or sedation among children undergoing laceration repair. METHODS A 1-year cross-sectional sample of children undergoing laceration repair in an urban tertiary-care pediatric emergency department was analyzed. Primary outcomes included the use of nonpharmacologic anxiolysis (presence of a child life specialist), pharmacologic anxiolysis, and procedural sedation. Predictors included race/ethnicity (Caucasian vs minority) and SES (represented by insurance status: private vs none/public). Bivariable analyses provided unadjusted odds ratios (ORs) for the association between predictors and outcomes, and logistic regression was used to obtain adjusted ORs for the provision of anxiolysis and sedation (adjusted for age, gender, acuity, provider type, length of laceration, complexity of repair, time of day, use of a topical anesthetic, and body site of laceration). RESULTS In the unadjusted analysis, a higher proportion of Caucasian children than minority children received nonpharmacologic anxiolysis and sedation, and a higher proportion of children with high SES received nonpharmacologic anxiolysis compared with children of low SES. However, these associations were not statistically significant once potential confounders were controlled in the adjusted analysis. CONCLUSIONS A very small proportion of children undergoing laceration repair at this single institution received pharmacologic anxiolysis and/or procedural sedation. We did not demonstrate racial/ethnic or socioeconomic disparities with respect to the management of procedure-related anxiety in children.