(Editor's Note: This edition of ED Management is a special issue on psychiatric patients. In this single-topic issue, we report on the biggest challenges EDs nationwide are facing and offer solutions for improving care, operating efficiently, and mitigating safety and legal risks.)
Although U.S. EDs have long struggled to meet the needs of patients who present with behavioral health (BH) concerns, new research suggests the COVID-19 pandemic exacerbated the problem. Since 2020, there has been a steadily expanding volume of children and teens who present with depression, suicidal ideation, anxiety, and other BH issues.1
Researchers reported one in five of these patients still will be waiting for care 12 hours after they arrive, and one in 13 will be waiting one day later. Furthermore, the authors noted more than half these patients who are stuck in the ED for lengthy periods are either suicidal or they have engaged in some type of self-harm.
It is a problem for EDs because patients who board there tie up beds and other resources that could be allocated to incoming patients. However, it is unhelpful for the young patients who linger in a setting that is not optimal for anyone who is psychologically distressed.
Alexander Janke, MD, lead author of this study, says while this problem is widespread, it is most apparent in community EDs without access to in-house psychiatric resources. Janke and colleagues studied data collected at 107 community hospitals between January 2020 and December 2021, along with information collected in 2019 at 33 of these facilities. The information was culled from the Clinical Emergency Data Registry, a resource developed by the American College of Emergency Physicians to measure emergency medicine outcomes and facilitate quality improvement.2
“This is a policy problem, and the long wait times in the ED represent a system failure,” says Janke, emergency physician at the University of Michigan and VA Ann Arbor Healthcare Systems. “That said, I know departments all over the country that are working to better integrate community-based psychiatric resources into their management, and to create workflows for the kids when lengths-of-stays are anticipated to be long.”
Karin Price, PhD, chief psychologist at Texas Children’s Hospital in Houston, says cases involving young people with BH concerns already were trending higher in her health system’s three EDs in early 2019, particularly among adolescents and preteens. “At that time, we were seeing between 50 and 100 patients coming in [to our EDs] specifically with BH crises,” she says. “Now, since the start of the pandemic, we are averaging between 350 and 450 of [these types of cases] per month across our three EDs.”
The patients are presenting predominantly with suicidal ideation, a suicide attempt, self-injurious behavior and, in some cases, aggression. While it is hard to pinpoint the cause, Price explains the increase in social media usage, pressures from school, and more familial disruption all were likely contributing factors. The pandemic exacerbated all those problems. Further, these issues, pandemic-related family stressors (e.g., economic instability and grief related to the loss of close family members or friends) likely played a role.
As a result of this surge in BH emergencies, there has been a significant increase in the number of kids who are transferring from the ED into inpatient psychiatric units in the community, but beds are not always immediately available. “We have a policy internally that we don’t want to board kids in our EDs. If we can’t find a correct place for them in the community, we will admit them to our acute medical floors,” Price says.
However, physicians, nurses, and care assistants who help these patients on inpatient floors are not trained to manage BH issues. Thus, the hospital has created a mobile team of BH professionals to assist the medical team with these patients. “We call it our BH support team, and it includes psychiatrists, psychologists, experts in autism and developmental disabilities, nurses, social workers, and case managers,” Price explains. “While our BH patients are admitted to our medical floors, this team is active and involved in assisting the medical team to provide the best care for these patients while they are admitted to the hospital.”
Price says she has just received approval to expand the BH staff working on site in the ED. This bigger team can work with more patients and consult with the family to figure out what is next. For example, ED-based BH professionals will determine whether patients need inpatient care or can be referred to mental health resources in the community and go home with their families.
For such an approach to work, there must be enough resources in the community to serve these families, and the hospital has been active on that front. While Price credits the health system with dedicating funding toward this problem, she notes it also is spearheading initiatives that are funded philanthropically. For instance, one initiative is focused on creating intensive outpatient programs for kids who may not require an inpatient psychiatric bed, but need more than a weekly appointment to manage their BH issue.
“These are programs where kids come and receive therapy three days a week for four hours a day ... and they develop the skills to be successful in their home environments,” Price says. “We definitely noticed here in our community that there were not enough intensive outpatient programs, and they weren’t really accessible to kids living in the community who have [Children’s Health Insurance Program] or Medicaid. One thing that has been important is creating that level of care so that kids who are in the ED don’t necessarily have to go to an inpatient facility.”
Another initiative involves working with the network of primary care pediatricians who are taking care of kids with BH needs. Price says this allows BH problems to be handled before they become full-blown crises. This is especially helpful for families who lack resources or who worry about stigma. “We know they are going to see their pediatrician. That is a provider they have come to trust and to value,” Price observes. “We can partner with those pediatricians to make sure that those kids are getting BH care there.”
Part of this initiative involves embedding BH clinicians into the pediatric practices so they are on hand to work with the young patients. However, these BH clinicians are there to help pediatricians learn how to care for these patients. For instance, Price notes her health system has created a weekly case conference during which pediatricians can access a child and adolescent psychiatrist. During these sessions, the pediatricians can discuss specific patients and receive guidance on appropriate psychiatric medicines.
Price’s health system also prepares a quarterly educational event that focuses on a topic that pediatricians determine. These sessions have addressed such topics as ADHD management, anxiety and depression, and managing disruptive behavior (including in the context of developmental concerns). “Most recently, we talked about managing the suicidal patient in the primary care environment,” Price says. “The [sessions] are all aimed at helping our pediatricians identify concerns, helping them to know what immediate steps they can take, and helping them to know how they can help the families access the resources they most need.”
Price advises colleagues there is not a simple solution to the problem. “We need to create systems of care for these kids with BH challenges,” she says. “We are really trying to make sure that we are closing the gaps ... so that kids are continually getting the right care, and therefore we are preventing as much as we can some of the exacerbations and increases in acuity.”
Children’s Hospital of Wisconsin in Milwaukee also has moved on several fronts to address a surge in young patients presenting to the ED with BH crises. For example, in 2020, the hospital used grant funding from the United Health Foundation to deploy its Crisis Response Team, an ED-based group that includes a psychiatrist, three mental and BH social workers, a mental and BH navigator, and a supervisor. This group ensures patients who present with mental health concerns receive the same kind of care, referrals, and follow-ups as patients who present with medical issues 24/7.
Amanda Quesnell, MSN, RN, NEA-BC, director of acute care mental and behavioral health at Children’s of Wisconsin, says every child who presents with a BH concern is evaluated from a medical standpoint and connected with a specialized BH social worker who conducts a full safety assessment. “The care team collaborates on a plan of care with consultation to a psychiatrist, when appropriate,” Quesnell explains. “The ED has a dedicated psychiatrist who is able to consult on cases. When not available, an on-call system is used.”
Quesnell notes every child and family will receive an individualized plan that may call for discharge from the ED, transfer to an inpatient psychiatric hospital, or admission to the hospital for medical monitoring or mental health monitoring if no inpatient psychiatric beds are available. Similar to Texas Children’s Hospital, Children’s of Wisconsin does not board children in the ED.
“Each child and family will receive a mental and BH navigator follow-up call to assess resources, follow up on appointments, and [address] any ongoing needs the family may have following the ED encounter,” Quesnell says.
When the Crisis Response Team was implemented, administrators estimated the group would support roughly 800 children per year. However, the team helped nearly 1,000 children in 2020, close to 1,400 in 2021, and 1,292 in 2022. Since implementation of the Crisis Response Team, there has been a slight reduction in the number of patients with BH concerns who have returned to the ED for care following an initial encounter.
In addition to providing funding for the Crisis Response Team, the United Health Foundation support also has helped provide de-escalation training and trauma-informed education to all ED nurses and medical staff. Such training can help clinicians defuse emotional or aggressive behavior and maintain a safe environment.
To further address the need for BH care in youth, Children’s of Wisconsin opened a walk-in clinic on the hospital campus in March 2022. This resource is designed for lower-acuity BH patients, but it also is an attempt to catch issues early before they become crises. While it is unclear how the walk-in clinic will affect the ED, it may have contributed to the slight decline in the number of BH patients presenting to the ED in 2022.
For facilities struggling with higher volumes of BH patients, Quesnell suggests developing a team approach that includes mental and BH professionals, providers, and support staff that can “wrap their arms” around families. “Continue to advocate for connections to ongoing care,” she says. “For example, our ED social workers are now able to schedule appointments with BH consultants in our primary care offices.”
REFERENCES
1. Janke AT, Nash KA, Goyal P, et al. Pediatric mental health visits with prolonged length of stay in community emergency departments during COVID-19. J Am Coll Emerg Physicians Open 2022;3:e12869.
2. American College of Emergency Physicians. Clinical Emergency Data Registry.
Behavioral health mobile teams, comprised of psychiatrists, psychologists, experts in autism and developmental disabilities, nurses, social workers, and case managers, can support medical teams caring for patients in crisis.
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