By Stacey Kusterbeck
EDs continue to see a surge of pediatric patients presenting with behavioral health needs. From 2011 to 2020, the percentage of mental health-related visits increased from 7% to 13% (of all pediatric ED visits), according to a group of researchers.1
“Because these patients are relying on EDs for care, there is a need to optimize ED throughput and behavioral health resources,” says Danielle Brathwaite, an MD/PhD candidate in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill.
Brathwaite and colleagues analyzed how a surge in demand for all types of emergency services has affected ED length of stay, wait time, and disposition for children seeking behavioral healthcare.2 Brathwaite and colleagues analyzed 14,092 pediatric psychiatric visits to eight North Carolina EDs that occurred from 2018-2020.
Overall, ED demand minimally affected throughput measures for pediatric psychiatric patients. Yet more pediatric demand, regardless of whether it was for behavioral health, extended certain throughput times. “In other words, the age of the patient was more of a dilemma for EDs than the nature of the complaint,” Brathwaite observes.
Patients who arrived by ambulance or with police were more likely to be admitted compared to patients who walked in. Patients with commercial insurance or Medicare recorded shorter lengths of stay compared to Medicaid patients. “This difference is probably due to the fact that the patient’s insurance status makes it easier or more difficult for ED providers to identify appropriate inpatient and/or outpatient resources for patients,” Brathwaite suggests.
For example, if a patient needs follow-up with an outpatient provider for medication management or psychotherapy, the provider must accept the patient’s insurance. Otherwise, the patient might need to rely on free and sliding-scale clinics that only take walk-ins. That results in longer ED stays, since patients cannot be discharged unless they have established a safe discharge plan. “This often includes a confirmed follow-up appointment on the books,” Brathwaite adds.
Thus, the easier it is to find someone an outpatient provider, the faster that patient can go home. If the patient is uninsured and their only option is a walk-in clinic, that person might need to stay in the ED longer for further stabilization. “There is a need to not just equip EDs with behavioral health resources, but with pediatric behavioral health resources,” Brathwaite concludes.
This is because children often present with different behavioral health needs than adults. However, in some departments, pediatric volumes are so low that board-certified pediatricians (or physicians with board certification in both pediatrics and emergency medicine) are unavailable. “It is not economical to have them when volumes are low,” Brathwaite admits. “But access to pediatric providers is necessary.”
EDs might rely on telemedicine from a third-party company, a sister hospital with pediatricians on staff, consult services from local pediatricians, or ensure at least one provider in the department is trained in pediatric care. “Even pediatrics experience, without a board certification, would be helpful,” Brathwaite offers. For instance, someone with family medicine board certification might still provide a level of tailored pediatrics service because they are trained to care for all ages.
Patients who need to be transferred to an inpatient bed at another institution waited longer in the ED compared to patients who could be discharged. There are many reasons for this, according to Brathwaite. Either beds do not exist, or the facilities with available beds are too far away, do not accept certain insurance, or are not designed for pediatric populations. “The ED essentially becomes a waiting room for these patients until they can get a bed,” Brathwaite says.
Another group of researchers examined children’s mental health ED revisits.3 “When kids come back to the emergency department multiple times for mental health reasons, it is a sign that we, as a healthcare system, are not giving them adequate care,” asserts Anna Cushing, MD, the study’s lead author and a pediatric emergency medicine physician at Children’s Hospital Los Angeles.
Cushing and colleagues analyzed 308,264 mental health visits from 217,865 unique patients at 38 U.S. children’s hospital EDs that occurred from 2015-2020. The researchers found 13.2% of patients returned for a mental health visit within six months. Mental health ED visits increased by 8% annually (in contrast, all other ED visits increased by 1.5% annually). Children with disruptive or impulse control disorders, psychotic disorders, and neurodevelopmental disorders (e.g., autism or ADHD) were more likely to make repeat ED visits.
“These patients are an important target for interventions during their first emergency department visit to prevent them from having to come back,” Cushing offers.
REFERENCES
1. Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National trends in mental health-related emergency department visits among youth, 2011-2020. JAMA 2023;329:1469-1477.
2. Brathwaite D, Strain A, Waller AE, et al. The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients. Am J Emerg Med 2023;64:174-183.
3. Cushing AM, Liberman DB, Pham PK, et al. Mental health revisits at US pediatric emergency departments. JAMA Pediatr 2023;177:168-176.
EDs might rely on telemedicine from a third-party company, a sister hospital with pediatricians on staff, consult services from local pediatricians, or ensure at least one provider in the department is trained in pediatric care.
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