Pediatric emergency medicine physicians' current practices and beliefs regarding mental health screening

Outcomes Following a Mental Health Care Intervention for Children in the Emergency Department: A Nonrandomized Clinical Trial

Importance

The emergency department (ED) is an important safety net for children experiencing mental and behavioral health crises and can serve as a navigational hub for families seeking support for these concerns.

Objectives

To evaluate the outcomes of a novel mental health care bundle on child well-being, satisfaction with care, and health system metrics.

Design, Setting, and Participants

Nonrandomized trial of 2 pediatric EDs in Alberta, Canada. Children younger than 18 years with mental and behavioral health presentations were enrolled before implementation (preimplementation: January 2020 to January 2021), at implementation onset (run-in: February 2021 to June 2021), and during bundle delivery (implementation: July 2021 to June 2022).

Intervention

The bundle involved risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit, if required.

Main Outcomes and Measures

The primary outcome, child well-being 30 days after the ED visit, was assessed using the Stirling Children's Wellbeing Scale (children aged <14 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 14-17 years). Change in well-being between the preimplementation and implementation periods was examined using interrupted time-series analysis and multivariable modeling. Changes in health system metrics (hospitalization, ED length of stay [LOS], and revisits) and care satisfaction were also examined.

Results

A total of 1412 patients (median [IQR] age, 13 [11-15] years), with 715 enrolled preimplementation (390 [54.5%] female; 55 [7.7%] First Nations, Inuit, or Métis; 46 [6.4%] South, Southcentral, or Southeast Asian; and 501 [70.1%] White) and 697 enrolled at implementation (357 [51.2%] female; 51 [7.3%] First Nations, Inuit, or Métis; 39 [5.6%] South, Southcentral, or Southeast Asian; and 511 [73.3%] White) were included in the analysis. There were no differences between study periods in well-being. Reduced well-being z scores were associated with mood disorder diagnosis (standardized mean difference, -0.14; 95% CI, -0.26 to -0.02) and nonbinary gender identity (standardized mean difference, -0.41; 95% CI, -0.62 to -0.19). The implementation period involved fewer hospitalizations (difference in hospitalizations, -6.9; 95% CI, -10.4 to -3.4) and longer ED LOS (1.1 hours; 95% CI, 0.7 to 1.4 hours). There were no differences between study periods in ED revisits or care satisfaction.

Conclusions and Relevance

In this study, the delivery of a care bundle was not associated with higher child well-being 30 days after an ED visit. Hospitalizations did decrease during bundle delivery, but ED LOS did not. These health system findings may have been affected by broader changes in patient volumes and flow processes that occurred during the COVID-19 pandemic, which took place as the study was conducted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04292379.

Using Behavioral Measures to Assess Suicide Risk in the Psychiatric Emergency Department for Youth

Suicide screening is critical in pediatric emergency departments (EDs). Behavioral measures of suicide risk may complement self-report measures. The current study examines suicide-specific behavioral measures and tests their potential short-term within-person effects among respondents, ability to discriminate future suicide attempt from suicidal ideation, and translation into interpretable categorical composite scores. The sample included 167 youth (10-17 years), presenting for suicide-related reasons to a pediatric psychiatric ED. During their ED visit, participants completed the Death/Life Implicit Association Test (IAT) and the Suicide Stroop Task. Recurrent suicidal thoughts and attempts were assessed within 6 months of the ED visit via medical records and email surveys. Youth displayed a decrease in the levels of distress and self-injurious desires (negative mood, desire to hurt themselves, and desire to die) after completing the behavioral tasks. The Death/Life IAT prospectively differentiated with 68% accuracy between youth who attempted suicide after their ED visit and those who had suicidal ideation but no attempt, p = 0.04, OR = 5.65, although this effect became marginally significant after controlling for self-report and demographic covariates. Neither the Suicide Stroop Task, nor the categorical composite scores predicted suicide attempts, ps = 0.08-0.87, ORs = 0.96-3.95. Behavioral measures of suicide risk administered in the ED do not appear to increase distress or self-injurious desires. They may be able to distinguish those who go on to attempt suicide (vs. consider suicide) within six months after discharge.

Providing mental health resources for pediatric patients with low-risk suicidality

BACKGROUND AND OBJECTIVES

Suicide is a leading cause of death among youth in the United States. Pediatric emergency department visits for non-psychiatric concerns present an opportunity to identify youth at risk for suicidality. This quality improvement initiative was undertaken to ensure that those patients identified as low risk for suicide receive resources, bridging the gap between identifying at-risk youth and providing them with appropriate follow up mental health resources. The aim of this project was to increase the proportion of after visit summaries containing mental health resources by 25 % within 6 months for medical patients who are found to have non-acute low suicide risk and are discharged from the emergency department.

METHODS

The primary outcome measure was the proportion of discharged medical patients who screened positive for suicidal ideation and were determined to be at low risk for suicide who received mental health resources on discharge before and after intervention. A multidisciplinary team targeted the following 3 key drivers: 1) multidisciplinary engagement 2) training and education of providers and 3) health information technology. Plan, Do, Study and Act cycles included the following: 1) an educational campaign with regular multidisciplinary meetings, educational updates, and email reminders; 2). an electronic health record change; and 3) An individual report to providers.

RESULTS

After the intervention, the percentage of medical patients with low-risk suicidality being discharged with mental health resources increased by more than 70 %.

CONCLUSIONS

A champion led multidisciplinary team, using PDSA methodology, can implement sustained improvements in mental health resource distribution.

Facilitating Access to Mental Health Services: A Stakeholder-Driven Improvement of the Children and Young People (CYP) as One Referral Platform

(1) Background: Pre-pandemic, child and adolescent mental health service (CAMHS) referrals were paper based in Liverpool and Sefton (England, United Kingdom), causing delays in waiting times. The "CYP as One" online mental health referral platform was co-created to overcome these challenges. (2) Methods: This study aims to improve "CYP as One" accessibility and usability and, subsequently, support CAMHS to improve waiting times. The current study utilised the Living Lab approach. We conducted content analysis on completed online referrals extracted from the "CYP as One" platform. These findings were supplemented by seven online focus groups, with 16-19-year-old young people, parents of children under 16, and health service providers. Thematic analysis was conducted on all data. (3) Results: The thematic analysis returned seven themes, namely (i) "CYP as One" vs. Traditional Referrals, (ii) Gender and Language Dynamics, (iii) Digital Empathy in Action, (iv) the Influence of the Provider Perspective, (v) Age and Social Sensitivity, (vi) Enhancing Access to Information, and (vii) Boosting Admin and Clinical Efficiency. (4) Conclusions: Digital content that seeks to replace in-person referrals can provide adequate support to children and young people who have faced difficulties accessing mental health services.

Designing Implementation Strategies for a Digital Suicide Safety Planning Intervention in a Psychiatric Emergency Department: Protocol for a Multimethod Research Project

BACKGROUND

Suicide prevention is currently a national health priority in Canada. Emergency departments (EDs) are critical settings for suicide prevention, and in our local psychiatric ED at the Centre for Addiction and Mental Health, we plan to embed an app-based tool called the Hope app to support suicide safety planning intervention. The app is free and available on app stores, and usability tests have been completed. As a next step to embed this new tool into the routine clinical workflow, research is needed to assess determinants of and design strategies for implementation with the end goal of routinization.

OBJECTIVE

The purpose of this 2-phased research is to implement the app in the routine clinical workflow in our local psychiatric ED. The specific objectives are as follows: (1) understanding ED clinicians' perceptions and experience of implementing the app in routine practice and identifying barriers to and facilitators of implementation (phase 1) and (2) using findings and outputs from phase 1 and collaborating with service users, families, and ED clinicians to co-design implementation strategies for the app (phase 2).

METHODS

We will use an integrated knowledge translation approach throughout this project. In phase 1, we will conduct interviews with ED clinicians to identify implementation determinants using a behavior change framework. In phase 2, a co-design team comprising clinicians, ED service users, and families will design implementation strategies that align with the determinants identified in phase 1.

RESULTS

This protocol presents detailed information about the entire structure of the 2-phased research project. Ethics approval for conducting the qualitative descriptive study (phase 1) has been obtained, and the recruitment and data collection processes will be completed no later than December 2023. Ethics approval for phase 2 is underway.

CONCLUSIONS

Involving multiple knowledge user groups early in the research and decision-making process is crucial for successful implementation. Although co-designing is commonly practiced during innovation development, there is often a misconception that the responsibility for implementing what has been designed falls on others. This research aims to fill this methodological gap in the health informatics literature. By the end of this project, we will have developed theory-informed implementation strategies to support Centre for Addiction and Mental Health ED clinicians in adopting the Hope app to complete safety planning intervention. These strategies, guided by a behavior change framework, will target clinicians' behavior change and seamlessly integrate the app into the routine clinical workflow. In addition, this research project will provide recommendations on how to involve multiple knowledge user groups and offer insights into how the methodology used can be adapted to other areas within the health informatics literature.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50643.

Barriers and facilitators to discussing parent mental health within child health care: Perspectives of parents raising a child with congenital heart disease

This study aimed to identify barriers and facilitators to discussing parent mental health within child health care for parents of children with congenital heart disease (CHD). Seventy-nine parents of young children with CHD who received care across 40 hospitals in the United States responded to questions about barriers and facilitators to discussing their mental health with their child's health care providers. Responses were analyzed using qualitative research methods. Parents described multiple barriers: (1) belief that parent mental health support was outside the care team's scope of practice, (2) perceived expectation to "stay strong," (3) fear of negative judgment or repercussion, (4) individual preferences for communication/support, (5) desire to maintain care resources on their child, (6) perceived need to compartmentalize emotions, and (7) negative reactions to past emotional disclosure. Parents also described several facilitators: (1) confidence in the care team's ability to provide support, (2) intentional efforts by the care team to provide support, (3) naturally extroverted tendencies, and (4) developing personal connections with health care providers. It is important that health care providers normalize the impact of child illness on the family and create an environment in which parents feel comfortable discussing mental health challenges.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Access to Firearms: Initiation of Firearm Screening Among Psychiatric Patients in a Pediatric Emergency Department

OBJECTIVE

Increase provider screening rates for firearm access among patients presenting to the pediatric emergency department (PED) for a psychiatric chief complaint.

METHODS

In this resident-driven quality improvement project, a retrospective chart review examined firearm access screening rates among patients presenting to the PED with the chief complaint of "psychiatric evaluation." After establishing our baseline screening rate, the first phase of our plan, do, study, act (PDSA) cycle included implementing Be SMART education for pediatric residents. We made Be SMART handouts available in the PED, created electronic medical record (EMR) templates to facilitate documentation, and emailed routine reminders to residents during their PED block. In the second PDSA cycle, the pediatric emergency medicine (PEM) fellows expanded our efforts to increase project awareness from a supervisory role.

RESULTS

The baseline screening rate was 14.7% (50 of 340). After PDSA 1, a center line shift occurred, and screening rates increased to 34.3% (297 of 867). After PDSA 2, screening rates increased to 35.7% (226 of 632). In the intervention phase, providers who received training screened 39.5% (238 of 603) of encounters versus providers who did not receive training screened 30.8% (276 of 896) of encounters. Of all encounters screened, 39.2% (205 of 523) screened positive for in-home firearms.

CONCLUSIONS

We improved firearm access screening rates in the PED using provider education, EMR prompts, and PEM fellow participation. Opportunities remain to promote firearm access screening and secure storage counseling in the PED.

The Association of Pediatric Emergency Medicine Physicians' Self-Identified Skills in Suicide Risk Assessment and Management With Training in Mental Health

OBJECTIVE

Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk.

METHODS

Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry.

RESULTS

The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence.

CONCLUSIONS

The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design Setting and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Pediatric emergency department physicians' perceptions of virtual mental health assessments for urgent needs

PURPOSE

Pressures related to the COVID-19 pandemic have created the need to develop innovative ways to deliver mental health care, especially for urgent needs. After the launch of a pediatric Emergency Department (ED) Virtual Care service, we aimed to evaluate pediatric ED physicians' experiences with the use of ED virtual care for mental health assessments.

METHODS

This mixed-methods study was conducted at a pediatric academic health center in Ontario, Canada. Pediatric ED physicians who conducted ED virtual mental health assessments from May to December 2020 were eligible. Participants completed a 22-question novel survey and were invited to participate in a focus group. Descriptive and thematic analyses were used to analyze the data.

RESULTS

Twenty-nine physicians provided mental health services through the ED virtual care platform. Twenty-five physicians (86% response rate) completed the survey and 3 (10%) participated in a focus group. While many agreed that virtual care benefits patients (67%), key barriers identified included time constraints, lack of mental health clinician support, and uncertainty around the pediatric ED physicians' role in these types of assessments. Despite these barriers, physicians recognized the potential benefit of the ED virtual care service for mental health assessments and were largely amenable to improving this process should mental health support be available.

CONCLUSIONS

While many physicians agreed that there is a potential benefit of the ED virtual care platform for urgent mental health assessments, time constraints and lack of confidence in providing satisfactory virtual mental health care with minimal mental health support limited its acceptability. These findings can inform the future implementation of mental health services using an innovative virtual ED platform.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial

INTRODUCTION

In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED).

METHODS

We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors.

RESULTS

A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02).

CONCLUSION

This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents' perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

Comparison of violence risk screening experiences of emergency department clinicians

OBJECTIVE

Individuals commonly present to the emergency department (ED) for care after violence and many are also at risk for subsequent self or other-directed violence. Screening for violence risk represents an important part of ED care, but is challenging to implement effectively. Feedback from ED providers is needed to characterize differences across provider types in order to facilitate implementation of enhanced screening practices.

METHODS

This qualitative focus group study examined the experiences of 6 psychiatric social workers, 16 emergency medicine physicians, and 15 psychiatric providers in conducting violence risk screening to elicit ideas about solutions and barriers.

RESULTS

Eight themes emerged: Approach to Patient Assessment, High-Yield Clinical Data in Risk Assessment, Suicide Risk Screen, ED Clinician Resources, Analysis of Professional Risk, Affective Response of Clinician, ED Role and Scope, and Clinical Management. All clinician types discussed the themes from their professional perspectives and generated important knowledge of violence risk screening practices.

CONCLUSIONS

The findings affirm the importance of interdisciplinary cooperation in addressing violence risk in the ED and emphasize the need for ongoing clinical education and feedback as well as the importance of optimizing efficiency.

Emergency mental health care for chi̇ldren and adolescents outside of regular working hours: 7 years outcomes from a tertiary hospital

OBJECTIVE

This study aims to define the clinical characteristics and management strategies of children and adolescents presenting with psychiatric crises to the emergency department (ED) of a tertiary health care facility outside of working hours, and to identify predictors of multiple ED visits among them.

METHODS

From January 2012 to December 2018, retrospective records of patients presenting with psychiatric symptoms to the ED and examined by a child psychiatrist after 5 p.m. on weekdays and for 24 h on weekends and public holidays were analyzed.

RESULTS

Our sample consisted of 1576 visits and 1364 patient (Female:Male=1.8:1, mean age=14.86 ± 2.72). The most common reason for visits was self-injurious thought or behaviors (SITB), and the most common diagnosis was depression. While depression was statistically more common in girls, attention deficit hyperactivity disorder, autism and/or intellectual disability (ASD/ID), psychotic disorders, and bipolar disorder were more common in boys. The forensic evaluation was the most common reason for visits among children younger than 6 years old. Of visits, 23% transferred to hospitalization. A history of mental health contact was the lowest in depression (37.5%), psychosis (34.1%), and substance use disorders (33%). Of patients, 10.8% had multiple visits. A history of mental health contacts, conduct disorder, ASD/ID, bipolar disorder, psychotic disorder, and dissociative disorder were predictors of multiple visits to ED with psychiatric reasons.

CONCLUSION

Emergency mental health care outside of regular working hours can be a critical step in the diagnosis and treatment of serious psychiatric disorders in children and adolescents.

The Impact of Universal Mental Health Screening on Pediatric Emergency Department Flow

OBJECTIVE AND HYPOTHESIS

Assess the impact of universal mental health screening with MyHEARTSMAP on emergency department (ED) flow, an important aspect of feasibility. We hypothesized that the difference in departmental level ED length of stay (LOS) for screening and matched nonscreening days is less than 30 minutes.

METHODS

We conducted a 2-center, retrospective cohort study between December 2017 and June 2019. At each center, random mental health screening days were assigned over the course of 15 consecutive months. We matched each 24-hour screening day to a unique nonscreening day based on: location (Center 1 or Center 2); day type (weekday: Monday-Thursday or weekend: Friday-Sunday); date (±28 days); and 24-hour volume (±15 patients). We collected retrospective patient flow data, including LOS, across all ED visits to determine the difference in departmental level median LOS between matched screening and nonscreening days.

RESULTS

There was not a statistically significant difference in departmental LOS between screening and nonscreening days. Overall, the difference in departmental LOS was -4.0 minutes (95% confidence interval, -9.8, 1.8) for screening days compared to nonscreening days, with a difference of -2.0 minutes (-9.0, 4.9) at Center 1 and -6.0 minutes (-15.4, 3.4) at Center 2.

CONCLUSIONS

Our findings show that universal mental health screening with MyHEARTSMAP can be implemented without a significant impact of ED LOS.

Interventions to change clinicians' behavior related to suicide prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine the functional mechanisms of interventions and how these characteristics can influence emergency department clinicians' behaviors related to suicide prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behaviour Change Wheel's intervention functions. Reported outcome measures were categorized. Findings were tabulated and synthesized narratively.

RESULTS

This review included a total of 70 sources, describing 66 different interventions. Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivization (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and organization-level barriers for a given context. The ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors; however, current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

Barriers to Universal Suicide Risk Screening for Youth in the Emergency Department

OBJECTIVE

Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research.

METHODS

A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model.

RESULTS

All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues.

CONCLUSIONS

The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

Psychiatric Education for Pediatric Emergency Medicine Fellows: Should We be Doing More?

The number of psychiatric encounters is steadily increasing across all pediatric emergency departments. Based on this growing national crisis, we hypothesized there is a lack of robust education in behavioral/mental health emergencies during pediatric emergency medicine (PEM) fellowship.

METHODS

This was a cross-sectional survey of PEM fellowship directors. The survey was submitted to the Pediatric Emergency Medicine Program Director Survey Committee via REDCap to all 83 fellowship directors.

RESULTS

Fifty-five (66%) PEM fellowship directors completed the survey from September 2019 to December 2019. Forty-three (78%) programs provide some type of didactic teaching, although only 7 (13%) programs offer more than 5 hours of didactics over 3 years of fellowship. Six (11%) programs offer electronic resources, 13 (24%) offer simulations in psychiatry, and only 4 (7%) programs require any type of psychiatry rotation. Forty-six (84%) programs do not currently use psychiatric emergencies as a competency for evaluating PEM fellows. Program directors felt significantly more confident in faculty than graduating fellows in the management of numerous diagnoses including agitation (P < 0.001), homicidal ideation (P = 0.044), neuroleptic malignant syndrome (P = 0.006), acute dystonia (P < 0.001), and heroin overdose (P = 0.022). Ninety-six percent felt online curricula would be helpful to address this knowledge gap.

CONCLUSIONS

Despite growing behavioral/mental health needs in the pediatric emergency department, there continues to be opportunity to improve psychiatric education during PEM fellowship. Program directors felt more confident in faculty than graduating fellows with several psychiatric diagnoses. Pediatric emergency medicine fellowship directors expressed a strong interest in online tools to assist in the education of PEM fellows.

Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review

OBJECTIVES

To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts.

METHODS

A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included.

RESULTS

All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%.

CONCLUSIONS

Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Validation and Feasibility of the ASQ Among Pediatric Medical and Surgical Inpatients

OBJECTIVES

To validate the use of a brief suicide risk screening tool, the Ask Suicide-Screening Questions (ASQ) instrument, in pediatric inpatient medical and surgical settings.

METHODS

Pediatric patients (10-21 years) hospitalized on inpatient medical and surgical units were recruited through convenience sampling for participation in a cross-sectional instrument validation study. The Suicidal Ideation Questionnaire was used as a standard criterion to validate the ASQ. Patient opinions about screening and parent consent to enroll in a suicide risk screening study were assessed to determine the feasibility of administering the ASQ in this venue.

RESULTS

A total of 600 pediatric medical inpatients were screened. Compared with the gold standard, the ASQ had strong psychometric properties, with a sensitivity of 96.67% (95% confidence interval [CI]: 82.78 to 99.92), a specificity of 91.05% (95% CI: 88.40 to 93.27), a negative predictive value of 99.81% (95% CI: 98.93 to 99.99), and an area under curve of 0.94 (95% CI: 0.90 to 0.97). Only 3 participants (0.5%) had acute positive screen results on the ASQ, endorsing current suicidal ideation, whereas 77 participants (12.8%) screened nonacute positive, and 48 participants (8.0%) reported a past suicide attempt.

CONCLUSIONS

The brief 4-item ASQ is a valid tool to detect elevated suicide risk in pediatric medical and surgical inpatients. Our findings also reveal that screening is feasible in terms of detection of suicidal thoughts and behaviors and is acceptable to parents and patients.

Pediatric Suicide Screening: A Review of the Evidence

BACKGROUND

Suicide rates are increasing for youths and suicide is the second leading cause of death for 10-24 year olds. This evidence-based practice project critically reviews literature regarding the effectiveness of pediatric suicide screening.

METHODS

A literature search was guided by the following question: In pediatric patients, does suicide screening at every health encounter compared to an annual screen increase clinician identification of patients at-risk. Ten articles met inclusion criteria and were critically appraised and synthesized.

FINDINGS

Youths had high rates of suicidal ideation (SI), anxiety, and depression. Pediatric universal suicide screening identified SI in youths with both psychiatric and non-psychiatric medical complaints. Patients with chronic health conditions reported higher rates of mental health symptoms and SI. A specific suicide screening instrument should be used as general mental health screens likely miss youths at-risk for SI. The Ask Suicide-Screening Questions tool is an easy to use and highly sensitive instrument for detecting suicide risk in youths.

DISCUSSION

Many youths that screen positive for SI do not have known mental health concerns and would have been missed if not asked directly. Universal screening for SI identifies at-risk youth and allows nurses and other providers to intervene. The need for universal screening across pediatric health care settings using brief, validated screening tools is paramount.

APPLICATION TO PRACTICE

Nurses working in pediatric settings should champion universal screening for SI. Unit-based quality improvement projects using the Plan-Do-Study-Act change cycle provides a model for instituting universal screening for SI.

Improving Youth Suicide Risk Screening and Assessment in a Pediatric Hospital Setting by Using The Joint Commission Guidelines

OBJECTIVES

Hospitals accredited by The Joint Commission (TJC) are now required to use a validated screening tool and a standardized method for assessment of suicide risk in all behavioral health patients. Our aims for this study were (1) to implement a TJC-compliant process of suicide risk screening and assessment in the pediatric emergency department (ED) and outpatient behavioral health clinic in a large tertiary care children's hospital, (2) to describe characteristics of this population related to suicide risk, and (3) to report the impact of this new process on ED length of stay (LOS).

METHODS

A workflow using the Columbia Suicide Severity Rating Scale was developed and implemented. Monthly reviews of compliance with screening and assessment were conducted. Descriptive statistics were used to define the study population, and multivariable regression was used to model factors associated with high suicide risk and discharge from the ED. ED LOS of behavioral health patients was compared before and after implementation.

RESULTS

Average compliance rates for screening was 83% in the ED and 65% in the outpatient clinics. Compliance with standardized assessments in the ED went from 0% before implementation to 88% after implementation. The analysis revealed that 72% of behavioral health patients in the ED and 18% of patients in behavioral health outpatient clinics had a positive suicide risk. ED LOS did not increase. The majority of patients screening at risk was discharged from the hospital after assessment.

CONCLUSIONS

A TJC-compliant process for suicide risk screening and assessment was implemented in the ED and outpatient behavioral health clinic for behavioral health patients without increasing ED LOS.

Outcome of pediatric emergency mental health visits: incidence and timing of suicide

OBJECTIVES

To determine the incidence, risk, and timing of mortality (unnatural and natural causes) among youth seen in a pediatric emergency department (ED) for mental health concerns, compared with matched non-mental health ED controls.

METHODS

This was a retrospective cohort study conducted at a quaternary pediatric ED in British Columbia. All visits for a mental health related condition between July 1st, 2005, and June 30th, 2015, were matched on age, sex, triage acuity, socioeconomic status, and year of visit to a non-mental health control visit. Mortality outcomes were obtained from vital statistics data through December 31st, 2016 (cumulative follow-up 74,390 person-years).

RESULTS

Among all cases in our study, including 6,210 youth seen for mental health concerns and 6,210 matched controls, a total of 13 died of suicide (7.5/100,000 person-years) and 33 died of suicide or indeterminate causes (44/100,000 person-years). All-cause mortality was significantly lower among mental health presentations (121.3/100,000 v. 214.5/100,000 person-years; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.37-0.78). The median time from initial emergency visit to suicide was 5.2 years (interquartile range, 4.2-7.3). Among mental health related visits, risk of death by suicide or indeterminate cause was three-fold that of matched controls (HR, 3.05 95%CI, 1.37-6.77).

CONCLUSIONS

While youth seeking emergency mental health care are at increased risk of death by unnatural causes, their overall mortality risk is lower than non-mental health controls. The protracted duration from initial presentation to suicide highlights the need for long-term surveillance and preventative care for youth seen in the ED for all mental health concerns.

The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool

OBJECTIVES

This effectiveness study aimed to evaluate the clinical use of the HEADS-ED tool for patients presenting to a pediatric emergency department (PED) for mental health (MH) care.

METHODS

In this pragmatic trial, PED physicians used the HEADS-ED to guide their assessment and identify areas of MH need in 639 patients (mean [SD], 15.16 [1.40] years; female, 72.6%) who presented to the emergency department with MH concerns between May 2013 and March 2014.

RESULTS

The HEADS-ED guided consultation to psychiatry/crisis, with 86% receiving a recommended consult. Those with a HEADS-ED score of greater than or equal to 8 and suicidality of 2 (relative risk, 2.64; confidence interval, 2.28-3.06) had a 164% increased risk of physicians requesting a consult compared with those with a score of less than 8 or greater than or equal to 8 with no suicidality of 2. The HEADS-ED mean score was significantly higher for those who received a consult (M = 6.91) than those who did not (M = 4.70; P = 0.000). Similarly, the mean score for those admitted was significantly higher (M = 7.21) than those discharged (M = 5.28; P = 0.000). Agreement on needs requiring action between PED physicians and crisis intervention workers was obtained for a subset of 140 patients and ranged from 62% to 93%.

CONCLUSIONS

Results support the HEADS-ED's use by PED physicians to help guide the assessment and referral process and for discussing the clinical needs of patients among health care providers using a common action-oriented language.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design, Setting, and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients

OBJECTIVE

Access to firearms is an independent risk factor for completed suicide and homicide, and the American Academy of Pediatrics recommends that pediatricians screen and counsel about firearm access and safe storage. This study investigates how often pediatric residents screen for access to firearms or counsel about risk-reduction in patients with suicidal or homicidal ideation.

METHODS

Retrospective chart review of visits by patients younger than the age of 19 years presenting to the pediatric emergency department (ED) of a tertiary academic medical center from January to December 2016. Visits were eligible if there was an ultimate ED discharge diagnosis of "suicidal ideation," "suicide attempt," or "homicidal ideation" as identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision codes and the patient was seen by a pediatric resident before evaluation by psychiatry. Descriptive statistics were used to analyze results.

RESULTS

Ninety-eight patients were evaluated by a pediatric resident for medical assessment before evaluation by a psychiatry team during the study period and were therefore eligible for inclusion. Screening for firearm access was documented by a pediatric resident in 5 of 98 (5.1%) patient encounters. Twenty-five patients (25.5%) had no documented screening for firearm access by any provider during the ED visit, including in 5 cases when patients were discharged home.

CONCLUSIONS

Pediatric residents rarely document screening for firearm access in patients with known suicidal or homicidal ideation who present to the ED. Additional understanding of the barriers to screening and potential strategies for improving screening and counseling are critical to providing appropriate care for high-risk pediatric patients.

MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth

BACKGROUND

Paediatric mental health-related visits to the emergency department are rising. However, few tools exist to identify concerns early and connect youth with appropriate mental healthcare. Our objective was to develop a digital youth psychosocial assessment and management tool (MyHEARTSMAP) and evaluate its inter-rater reliability when self-administered by a community-based sample of youth and parents.

METHODS

We conducted a multiphasic, multimethod study. In phase 1, focus group sessions were used to inform tool development, through an iterative modification process. In phase 2, a cross-sectional study was conducted in two rounds of evaluation, where participants used MyHEARTSMAP to assess 25 fictional cases.

RESULTS

MyHEARTSMAP displays good face and content validity, as supported by feedback from phase 1 focus groups with youth and parents (n=38). Among phase 2 participants (n=30), the tool showed moderate to excellent agreement across all psychosocial sections (κ=0.76-0.98).

CONCLUSIONS

Our findings show that MyHEARTSMAP is an approachable and interpretable psychosocial assessment and management tool that can be reliably applied by a diverse community sample of youth and parents.

Problem Behaviors and Psychological Distress Among Teens Seen in a National Sample of Emergency Departments

BACKGROUND

Problem behaviors, such as substance use and peer aggression, frequently coexist and are common among youth seen in emergency departments (EDs). EDs are increasingly urged to screen for both psychological distress and problem behaviors.

OBJECTIVE

To inform screening and intervention efforts, we aimed to identify classes of problematic substance use and peer aggression in a sample of adolescents from 16 pediatric EDs, and to examine the relative prevalence of psychological distress in identified classes.

METHODS

We completed a cross-sectional survey of youth (n = 5001) presenting for any reason to 16 pediatric EDs across the United States, with the use of validated measures of demographics, alcohol and substance use, and peer aggression. We used standard latent class analysis techniques to create behavioral risk classes of adolescents based on violence and substance use variables; then we conducted logistic regression to examine the relationship between psychological distress and the latent classes.

RESULTS

Three classes of problem behaviors were identified: low-risk (few problem behaviors, 91.2% of sample), medium risk (high cigarette smoking; moderate violence, alcohol/substance use; 5.2%), and high risk (high levels of all problem behaviors, 3.5%). A significant directional association (P < .001) between worse psychological distress and higher-risk behavior classes was noted, even after adjusting for demographics.

CONCLUSIONS

Youth seen in the ED for any reason who report higher levels of past-year substance use and peer aggression are significantly more likely to report negative mood symptoms. Targeted screening and interventions for this population may be indicated.

Suicide Evaluation in the Pediatric Emergency Setting

Suicide is 1 of the top 3 leading causes of death in the pediatric population and a serious public health concern. There are evidence-based screening tools for suicide in the pediatric population; however, predicting suicide risks can be a difficult task. The emergency department is an essential source of mental health care for youths and can serve as an important opportunity for suicide screening and subsequent targeted interventions and resource management. More research is needed in emergency department-based screening algorithms and evidence-driven interventions in the pediatric population.

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.

Identifying Undiagnosed Pediatric Mental Illness in the Emergency Department

BACKGROUND

It is well known that pediatric psychiatric patients frequent emergency department (ED), but the number of patients with undiagnosed psychiatric illness presenting to an ED is not well known. Identification and referral of these patients may provide an opportunity for improved patient care. The primary study objective was to identify a tool that can screen for unsuspected psychiatric illness in pediatric patients who present to the ED with non-psychiatric-related complaints.

METHODS

The MINI International Neuropsychiatric Interview for Children and Adolescents screening tool was administered to 200 pediatric consenting patients and guardians. The inclusion criteria were English-speaking patients who presented in the ED with a nonpsychiatric complaint who were stable and able to communicate. The study was conducted in a level 1 trauma center ED of an inner-city hospital that serves a predominantly African American and Hispanic population. This study was institutional review board approved.

RESULTS

The study populations consisted of 53% African American (107), 45% Hispanic (90), 1% white (2), and 0.5% Asian (1). Their age range was divided, with 49% between 12 and 14 years (98) and 51% between 15 and 17 years (102). The sex was evenly split, with 50% male (100) and 50% female (100). The 41% who did screen positive for an undiagnosed mental illness had a range of diagnoses. The top modules with positive results were oppositional defiant (13.5%, 27), attention-deficit/hyperactivity disorder (13%, 25), depression (10%, 11), conduct disorder (9%, 19), and anxiety (5%, 11).

CONCLUSIONS

The pediatric Mini International Neuropsychiatric Interview was effective in screening for undiagnosed mental illness in pediatric patients who presented to the ED with no psychiatric-related illness. The screening tool indicated that 41% of pediatric patients screened positive for an undiagnosed mental illness, with attention deficit-related disorders being the most widely seen. Further study should be conducted to test the tools used in a range of ED settings.

Screening to Identify Groups of Pediatric Emergency Department Patients Using Latent Class Analysis of Reported Suicidal Ideation and Behavior and Non-Suicidal Self-Injury

Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages 14-24; 31% Caucasian; 67% female) distinguished 6 groups with varying histories of suicidal ideation and behavior based on items endorsed on the Behavioral Health Screen, a web based, nurse-initiated screening tool. As expected, the more severe suicidality groups reported higher levels of depressive symptoms, traumatic distress, and substance abuse symptoms. Findings support the validity of the BHS and its utility as a medical decision tool to help ED staff evaluate the severity of patients' suicidality.

Barriers and Facilitators to Implementing the HEADS-ED: A Rapid Screening Tool for Pediatric Patients in Emergency Departments

OBJECTIVES

This study sought to identify barriers and facilitators to the implementation of the HEADS-ED, a screening tool appropriate for use in the emergency department (ED) that facilitates standardized assessments, discharge planning, charting, and linking pediatric mental health patients to appropriate community resources.

METHODS

A qualitative theory-based design was used to identify barriers and facilitators to implementing the HEADS-ED tool. Focus groups were conducted with participants recruited from 6 different ED settings across 2 provinces (Ontario and Nova Scotia). The Theoretical Domains Framework was used as a conceptual framework to guide data collection and to identify themes from focus group discussions.

RESULTS

The following themes spanning 12 domains were identified as reflective of participants' beliefs about the barriers and facilitators to implementing the HEADS-ED tool: knowledge, skills, beliefs about capabilities, social professional role and identity, optimism, beliefs about consequences, reinforcement, environmental context and resources, social influences, emotion, behavioral regulation and memory, and attention and decision process.

CONCLUSIONS

The HEADS-ED has the potential to address the need for better discharge planning, complete charting, and standardized assessments for the increasing population of pediatric mental health patients who present to EDs. This study has identified potential barriers and facilitators, which should be considered when developing an implementation plan for adopting the HEADS-ED tool into practice within EDs.

Emergency Department Utilization Among Assault-Injured Youth: Implications for Youth Violence Screening

OBJECTIVE

Assault is a common cause of youth emergency department (ED) visits. Little is known about prior ED utilization patterns among assault-injured youth. This study's objectives were to determine whether, and how, prior ED visit history distinguishes assault-injured youth from unintentionally injured youth.

METHODS

A 5-year retrospective, case-control study was conducted using a hospital billing database. Youth ages 13 to 24 years presenting to the ED of an urban level 1 trauma center in 2011 with an E-code of physical assault- or weapon-related injuries were compared 1:1 to randomly assigned, age- and sex-matched controls with an E-code corresponding to unintentional injury. Bivariate, t test, Wilcoxon rank sum tests, and conditional logistic regression were performed to determine how previous ED visits distinguished assault-injured youth from unintentionally injured youth.

RESULTS

In 2011, 964 patients presented with assault-related injuries. Over the previous 5 years, assault-injured youth had a median of 1 prior ED visit (interquartile range, 0-3); unintentionally injured youth had a median of zero prior ED visits (interquartile range, 0-2). Assault-injured youth had significantly higher median numbers of previous psychiatric and assault-related ED visits when compared to unintentionally injured youth. A youth with 1 previous psychiatric ED visit had a 4-fold increased odds (adjusted odds ratio [AOR], 4.05; 95% confidence interval, 2.41-6.83) of having a 2011 assault-related ED visit compared to unintentionally injured youth.

CONCLUSIONS

Assault-injured youth are more likely to have had prior ED use particularly for psychiatric illnesses and assault-related injury. Targeted youth violence screening may be appropriate for such patients.

A Systematic Review of Instruments to Identify Mental Health and Substance Use Problems Among Children in the Emergency Department

OBJECTIVE

Specialized instruments to screen and diagnose mental health problems in children and adolescents are not yet standard components of clinical assessments in emergency departments (EDs). We conducted a systematic review to investigate the psychometric properties, accuracy, and performance metrics of instruments used in the ED to identify pediatric mental health and substance use problems.

METHODS

We searched seven electronic databases and the gray literature for psychometric validation studies, diagnostic studies, and cohort studies that assessed any instrument to screen for or diagnose mental illness, emotional or behavioral problems, or substance use disorders. Studies had to include children and adolescents with mental health presentations or positive screens for substance use. Two reviewers independently screened studies for relevance and quality. Diagnostic study quality was assessed with the four QUADAS-2 domains. Psychometric study quality was assessed with published criteria for instrument reliability, validity, and usability. We present a descriptive analysis of the reported psychometric properties and diagnostic performance of instruments for each study.

RESULTS

Of the 4,832 references screened, 14 met inclusion criteria. Included studies evaluate 18 instruments for identifying suicide risk (six studies), alcohol use disorders (six studies), mood disorders (one study), and ED decision making (need for assessment, admission; one study). Nine studies include a psychometric focus but quality varies, with no studies fully meeting criteria for reliability, validity, and usability. Seven studies examine diagnostic performance of an instrument, but no study has a low risk of bias for all QUADAS-2 domains. The HEADS-ED instrument has good inter-rater reliability (r = 0.785) for identifying general mental health problems and modest evidence for ruling in patients requiring hospital admission (positive likelihood ratio [LR+] = 6.30). Internal consistency (reliability) varies for instruments to screen for suicide risk (α = 0.46-0.97), and no instruments have both high sensitivity and high specificity. The Ask Suicide-Screening Questions (ASQ) is highly sensitive (98%) and has strong evidence for ruling out risk (negative likelihood ratio [LR-] = 0.04). Among screening instruments for alcohol use disorders, internal consistency is high for the consumption subscale of the Alcohol Use Disorders Identification Test (α = 0.83-0.88) and the Adolescent Drinking Index (α = 0.92). Both instruments also had sound internal validity. Diagnostically, a two-item instrument based on DSM-IV criteria is the most accurate in identifying patients with a disorder (area under the curve = 0.89) and has modest evidence for ruling in and out risk (LR+ = 8.80, LR- = 0.13).

CONCLUSIONS

From available evidence, we recommend that ED clinicians use 1) the HEADS-ED to rule in ED admission among pediatric patients with visits for mental health care, 2) the ASQ to rule out suicide risk among pediatric patients with any visit type, and 3) the DSM-IV two-item instrument to rule in/rule out alcohol use disorders among pediatric patients currently using alcohol. These instruments require minimal to no training or time commitment. We also recommend that clinicians become familiar with each instrument's psychometric properties to understand the quality of the evidence base. In this review, however, we identify methodologic limitations in the evidence base. To develop a robust evidence base, additional research is necessary.

Mental Health Screening Among Adolescents and Young Adults in the Emergency Department

OBJECTIVE

To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints.

METHODS

An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, χ test, Mann-Whitney U test, and Spearman correlation.

RESULTS

Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered "yes" to at least 1 ED-DRS item; asymptomatic patients answered "no" to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation.

CONCLUSIONS

Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Trends in Pediatric Emergency Department Utilization for Mental Health-Related Visits

OBJECTIVE

To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 11 [corrected] years at a tertiary care hospital.

STUDY DESIGN

We conducted a retrospective cohort study of tertiary PED visits from 2002 [corrected] to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to non-mental health [corrected] PED visits. Descriptive statistics were used to summarize the results.

RESULTS

We observed a 47% increase in the number of mental health presentations compared with a 27.5% [corrected] increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (32.2% [corrected] yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 53.7% [corrected] increase in the number of mental health-related visits resulting in admission.

CONCLUSION

Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.

Emotion regulation and adolescent suicide: a proposal for physician education

Suicide is the second leading cause of death among adolescents aged 14-19 years. Pediatricians report strong interest in receiving additional training to reduce suicide mortality, and physician education is one of the most robust means of suicide prevention. However, many studies suggest that existing educational methods and means leave much room for improvement. In light of the emerging evidence that emotion regulation (ER) deficits are significantly associated with adolescent suicide, this paper proposes the untested hypothesis that a module on the brain-based ER system may strengthen existing methods of provider education. The ER system and the evidence supporting its association with adolescent suicide are reviewed. The ability to ground an approach to suicide prevention within this brain-based medical model may be appealing to pediatricians; its transdiagnostic breadth and dimensional makeup may also be appealing to pediatricians. Most importantly, its emphasis on the negative effects of impoverished self-regulation broaden non-specialist concern from a restriction upon withdrawn, depressed adolescents to those with a wide range of psychopathology. Implications and further considerations are discussed.

Screening for post-traumatic stress disorder after injury in the pediatric emergency department--a systematic review protocol

BACKGROUND

Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.

METHODS

Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data (specificity, positive and negative likelihood/odds ratios) where appropriate.

DISCUSSION

Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.

TRIALS REGISTRATION

PROSPERO registration: CRD42013004893.

Depression screening in adolescents in the United States: a national study of ambulatory office-based practice

OBJECTIVE

To determine the frequency of depression screening during ambulatory, office-based visits for adolescents seen in general/family medicine or pediatric practices in the United States using nationally representative data; to determine the patient-, provider-, and visit-level factors associated with depression screening during ambulatory visits to inform recommendations to promote screening.

METHODS

This cross-sectional study used the 2005-2010 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Data were limited to ambulatory, office-based visits to general/family medicine or pediatrics clinics for adolescents aged 12 to 18 years who did not have a documented diagnosis of depression.

RESULTS

Depression screening was rare (0.2%; 95% confidence interval [CI] 0.1-0.3), and it was 80% less likely to occur during visits for Hispanic compared to non-Hispanic white adolescents (adjusted odds ratio [aOR] 0.2, 95% CI 0.1-0.7). Depression screening was 9.1 times more likely in the Northeast compared to the West (aOR 9.1, 95% CI 2.2-38.1) if there were no visits within past 12 months compared to 6 or more visits (aOR 6.1; 95% CI 1.8-20.4), and if stress management (aOR 24.2, 95% CI 11.8-49.5) or other mental health counseling (aOR 5.2, 95% CI 1.2-23.6) were provided.

CONCLUSIONS

Depression screening for adolescents is rare and is associated with racial/ethnic and regional disparities. The integration of behavioral and mental health services within the patient-centered medical home might assist providers in identifying and treating depression and in addressing such disparities.

Knowledge, attitudes, and practices of emergency department providers in the care of suicidal patients

BACKGROUND

We sought to examine the knowledge, attitudes, and practices of emergency department (ED) providers concerning suicidal patient care and to identify characteristics associated with screening for suicidal ideation (SI).

METHODS

Six hundred thirty-one providers at eight EDs completed a voluntary, anonymous survey (79% response rate).

RESULTS

The median participant age was 35 (interquartile range: 30-44) years and 57% of the participants were females. Half (48%) were nurses and half were attending (22%) or resident (30%) physicians. More expressed confidence in SI screening skills (81-91%) than in skills to assess risk severity (64-70%), counsel patients (46-56%), or create safety plans (23-40%), with some differences between providers. Few thought mental health provider staffing was almost always sufficient (6-20%) or that suicidal patient treatment was almost always a top ED priority (15-21%). More nurses (37%, 95% confidence interval [CI] 31-42%) than physicians (7%, 95% CI 4-10%) reported screening most or all patients for SI; this difference persisted after multivariable adjustment. In multivariable analysis, other factors associated with screening most or all patients for SI were self-confidence in skills, (odds ratio [OR] 1.60, 95% CI 1.17-2.18), feeling that suicidal patient care was a top ED priority (OR 1.73, 95% CI 1.11-2.69) and 5+ postgraduate years of clinical experience (OR 2.06, 95% CI 1.03-4.13).

CONCLUSIONS

ED providers reported confidence in suicide screening skills but gaps in further assessment, counseling, or referral skills. Efforts to promote better identification of suicidal patients should be accompanied by a commensurate effort to improve risk assessment and management skills, along with improved access to mental health specialists.

Nonsuicidal self-injury among adolescents: a training priority for primary care providers

Primary care providers were surveyed to determine how prepared they feel to address nonsuicidal self-injury (NSSI) among adolescents, their interest in training on NSSI, and factors associated with routinely asking about NSSI when providing health supervision. Participants included family medicine physicians (n = 260), pediatricians (n = 127), family nurse practitioners (n = 96), and pediatric nurse practitioners (n = 54). Almost 50% felt unprepared to address NSSI, and over 70% wanted training in this area. Overall, relative to other areas of mental health care, clinicians felt least prepared to address and wanted more training on NSSI. Just 27% reported they routinely inquired about NSSI during health supervision. Factors associated with routinely asking about NSSI were identifying as female (OR = 2.37; 95% CI = 1.25-4.49), feeling better prepared to address NSSI (OR = 1.51; 95% CI = 1.04-2.20), and more frequently using a psychosocial interview to identify adolescents in distress (OR = 1.23; 95% CI = 1.02-1.48). Teaching clinicians to assess NSSI within a psychosocial interview may increase screening for and identification of the behavior among adolescents in primary care.

Depression screening and management among adolescents in primary care: factors associated with best practice

OBJECTIVE

To compare depression identification and management perceptions and practices between professions and disciplines in primary care and examine factors that increase the likelihood of administering a standardized depression screening instrument, asking about patients' depressive symptoms, and using best practice when managing depressed adolescents.

METHODS

Data came from an online survey of clinicians in Minnesota (20% response rate). Analyses involved bivariate tests and linear regressions.

RESULTS

The analytic sample comprised 260 family medicine physicians, 127 pediatricians, 96 family nurse practitioners, and 54 pediatric nurse practitioners. Overall, few differences emerged between physicians and nurse practitioners or family and pediatric clinicians regarding addressing depression among adolescents. Two factors associated with administering a standardized instrument included having clear protocols for follow-up after depression screening and feeling better prepared to address depression among adolescents.

CONCLUSIONS

Enhancing clinicians' competence to address depression and developing postscreening protocols could help providers implement universal screening in primary care.

Emergency Department Screening for Adolescent Mental Health Disorders: The Who, What, When, Where, Why and How It Could and Should Be Done

Mental health problems are a significant cause of morbidity and mortality among pediatric populations. Screening for these problems can result in earlier identification and increase treatment and improve outcomes for these children and adolescents. The emergency department (ED) is an ideal site for such screening. Pediatric ED patients are known to be at higher risk for mental health problems. For many, an ED visit is one of the few opportunities to identify and intervene with these children and adolescents. A number of brief, efficient screening instruments have been developed for the ED setting. Screening for mental health problems is both feasible and acceptable to ED patients, parents, and caregivers.

Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department

OBJECTIVE

To develop a brief screening instrument to assess the risk for suicide in pediatric emergency department patients.

DESIGN

A prospective, cross-sectional instrument-development study evaluated 17 candidate screening questions assessing suicide risk in young patients. The Suicidal Ideation Questionnaire served as the criterion standard.

SETTING

Three urban, pediatric emergency departments associated with tertiary care teaching hospitals.

PARTICIPANTS

A convenience sample of 524 patients aged 10 to 21 years who presented with either medical/surgical or psychiatric chief concerns to the emergency department between September 10, 2008, and January 5, 2011.

MAIN EXPOSURES

Participants answered 17 candidate questions followed by the Suicidal Ideation Questionnaire.

MAIN OUTCOME MEASURES

Sensitivity, specificity, predictive values, likelihood ratios, and area under the receiver operating characteristic curves of the best-fitting combinations of screening questions for detecting elevated risk for suicide.

RESULTS

A total of 524 patients were screened (344 medical/surgical and 180 psychiatric). Fourteen of the medical/surgical patients (4%) and 84 of the psychiatric patients (47%) were at elevated suicide risk on the Suicidal Ideation Questionnaire. Of the 17 candidate questions, the best-fitting model comprised 4 questions assessing current thoughts of being better off dead, current wish to die, current suicidal ideation, and past suicide attempt. This model had a sensitivity of 96.9% (95% CI, 91.3-99.4), specificity of 87.6% (95% CI, 84.0-90.5), and negative predictive values of 99.7% (95% CI, 98.2-99.9) for medical/surgical patients and 96.9% (95% CI, 89.3-99.6) for psychiatric patients.

CONCLUSIONS

A 4-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and negative predictive value, can identify the risk for suicide in patients presenting to pediatric emergency departments.