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House SA, Arakelyan M, Acquilano SC, Roche L, Leyenaar JK. Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding. Hosp Pediatr 2024; 14:394-402. [PMID: 38577744 DOI: 10.1542/hpeds.2023-007688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric "boarding"). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital's approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.
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Affiliation(s)
- Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire; and
- The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire
| | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire; and
| | - Leigh Roche
- The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire; and
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Hoffmann JA, Carter CP, Olsen CS, Ashby D, Bouvay KL, Duffy SJ, Chamberlain JM, Chaudhary SS, Glomb NW, Grupp-Phelan J, Haasz M, O'Donnell EP, Saidinejad M, Shihabuddin BS, Tzimenatos L, Uspal NG, Zorc JJ, Cook LJ, Alpern ER. Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study. Acad Emerg Med 2024. [PMID: 38563444 DOI: 10.1111/acem.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/20/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. METHODS We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. RESULTS We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). CONCLUSIONS During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.
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Affiliation(s)
- Jennifer A Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Camille P Carter
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - David Ashby
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kamali L Bouvay
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Susan J Duffy
- Department of Emergency Medicine, Brown University, Hasbro Children's Hospital, Providence, Rhode Island, USA
- Department of Pediatrics, Brown University, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA
| | - Sofia S Chaudhary
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nicolaus W Glomb
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Maya Haasz
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Erin P O'Donnell
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohsen Saidinejad
- Department of Emergency Medicine, The Lundquist Institute for Biomedical Innovation at Harbor UCLA, Harbor UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Bashar S Shihabuddin
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis, Sacramento, California, USA
| | - Neil G Uspal
- Division of Emergency Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Joseph J Zorc
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lawrence J Cook
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Zipursky AR, Olson KL, Bode L, Geva A, Jones J, Mandl KD, McMurry A. Emergency department visits and boarding for pediatric patients with suicidality before and during the COVID-19 pandemic. PLoS One 2023; 18:e0286035. [PMID: 37910582 PMCID: PMC10619773 DOI: 10.1371/journal.pone.0286035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/15/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE To quantify the increase in pediatric patients presenting to the emergency department with suicidality before and during the COVID-19 pandemic, and the subsequent impact on emergency department length of stay and boarding. METHODS This retrospective cohort study from June 1, 2016, to October 31, 2022, identified patients ages 6 to 21 presenting to the emergency department at a pediatric academic medical center with suicidality using ICD-10 codes. Number of emergency department encounters for suicidality, demographic characteristics of patients with suicidality, and emergency department length of stay were compared before and during the COVID-19 pandemic. Unobserved components models were used to describe monthly counts of emergency department encounters for suicidality. RESULTS There were 179,736 patient encounters to the emergency department during the study period, 6,215 (3.5%) for suicidality. There were, on average, more encounters for suicidality each month during the COVID-19 pandemic than before the COVID-19 pandemic. A time series unobserved components model demonstrated a temporary drop of 32.7 encounters for suicidality in April and May of 2020 (p<0.001), followed by a sustained increase of 31.2 encounters starting in July 2020 (p = 0.003). The average length of stay for patients that boarded in the emergency department with a diagnosis of suicidality was 37.4 hours longer during the COVID-19 pandemic compared to before the COVID-19 pandemic (p<0.001). CONCLUSIONS The number of encounters for suicidality among pediatric patients and the emergency department length of stay for psychiatry boarders has increased during the COVID-19 pandemic. There is a need for acute care mental health services and solutions to emergency department capacity issues.
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Affiliation(s)
- Amy R. Zipursky
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Karen L. Olson
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Louisa Bode
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Alon Geva
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - James Jones
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth D. Mandl
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Andrew McMurry
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
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Ketabchi B, Hoffmann JA. Supporting Youths During Mental Health Boarding: It's About Time. J Pediatr 2023; 255:8-11. [PMID: 36460080 PMCID: PMC10121726 DOI: 10.1016/j.jpeds.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Bijan Ketabchi
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Leyenaar JK, Arakelyan M, Acquilano SC, Gilbert TL, Craig JT, Lee CN, Kodak SG, Ignatova E, Mudge LA, House SA, Brady RE. I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding. J Adolesc Health 2023; 72:923-932. [PMID: 36870901 DOI: 10.1016/j.jadohealth.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Abstract
PURPOSE Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE. METHODS A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically. RESULTS Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers. DISCUSSION I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.
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Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire
| | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | | | - James T Craig
- Department of Psychiatry, Dartmouth Health, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Chloe N Lee
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Elizaveta Ignatova
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire
| | | | - Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Robert E Brady
- Department of Psychiatry, Dartmouth Health, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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