Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001

Transatlantic transferability and replicability of machine-learning algorithms to predict mental health crises

Transferring and replicating predictive algorithms across healthcare systems constitutes a unique yet crucial challenge that needs to be addressed to enable the widespread adoption of machine learning in healthcare. In this study, we explored the impact of important differences across healthcare systems and the associated Electronic Health Records (EHRs) on machine-learning algorithms to predict mental health crises, up to 28 days in advance. We evaluated both the transferability and replicability of such machine learning models, and for this purpose, we trained six models using features and methods developed on EHR data from the Birmingham and Solihull Mental Health NHS Foundation Trust in the UK. These machine learning models were then used to predict the mental health crises of 2907 patients seen at the Rush University System for Health in the US between 2018 and 2020. The best one was trained on a combination of US-specific structured features and frequency features from anonymized patient notes and achieved an AUROC of 0.837. A model with comparable performance, originally trained using UK structured data, was transferred and then tuned using US data, achieving an AUROC of 0.826. Our findings establish the feasibility of transferring and replicating machine learning models to predict mental health crises across diverse hospital systems.

Patterns and characteristics of visits to psychiatric emergency departments: a three-year data study in China

The composition and characteristics of emergency patients in the Affiliated Brain Hospital, Guangzhou Medical University during 2020-2022 were retrospectively analyzed to provide data support for the optimization of the process of psychiatric emergency and the elastic allocation of emergency medical staff. This study collected data from patients who sought medical attention at the emergency department of the Affiliated Brain Hospital, Guangzhou Medical University between January 1, 2020, and December 31, 2022. The fundamental information of these patients was statistically analyzed using descriptive analytic methods. In addition, a comprehensive statistical analysis was performed on the data of patient visits, which included precise triage time points, months, and seasons, in order to evaluate the temporal distribution of patient visits. The patient population had an average age of 36.4 years and was slightly more female (54.08%). The mean age of the male and female patients was 36.4 ± 18.91 and 36.4 ± 16.80 years, respectively. There was no statistically significant age difference between the male and female patients (p > 0.05). The top five diseases were mental disorder (6,483 cases), bipolar disorder (3,017 cases), depressive episode (2522 cases), schizophrenia (1778 cases) and anxiety state (1097 cases), accounting for 35.63%, 16.58%, 13.86%, 9.77% and 6.03% of the total, respectively. Additionally, a notable record of psychiatric drug intoxication was noted. Significant comorbidity with physical disorders, such as hypertension (9.36%), hypokalemia (3.41%), diabetes (2.83%), and cerebral infarction (2.79%), was also seen. The results of seasonal and monthly analysis indicated that emergency attendance patterns fluctuated, peaking in the spring and fall. The patterns of daily visits also revealed two peak times. The first peak occurs from 8:00 to 10:00, and the second peak occurs from 14:00 to 16:00. This study emphasizes the increasing occurrence of mental problems in psychiatric crises, particularly among younger populations, underscoring the necessity for comprehensive care methods. Specialized treatment methods and collaborative networks are required to address the substantial prevalence of psychiatric medication poisoning. Efficient allocation of resources and heightened security protocols are vital in emergency departments, particularly during periods of high demand and in handling instances of patient hostility.

Macroeconomic antecedents of racial disparities in psychiatric-related emergency department visits

Objective

To test whether monthly declines in aggregate employment precede a rise in African American psychiatric-related ED visits (PREDVs) relative to white visits among low-income, working-age populations.

Design

This study used repeated cross-sectional time series data for 6.7 million PREDVs among African Americans and white individuals from the State Emergency Department Database in 48 Metropolitan Statistical Areas (MSAs) across four states (Arizona, California, New York, New Jersey) from 2006 to 2011. MSA-level monthly employment data were obtained from the US Bureau of Labor Statistics. The outcome was specified as the race of a PREDV (African American = 1, white = 0). The exposure was operationalized as monthly percent change in MSA-level aggregate employment lagged by 0 to 3 months. Analysis included logistic regressions with county, month and year fixed effects, and clustered standard errors to examine the relation between odds of an African American PREDV (relative to white) following 0 to 3 months lag of MSA-level aggregate employment change.

Findings

Logistic regression results indicate that the odds of PREDVs for publicly insured, working-age African Americans (relative to white individuals) increase 3 months after ambient employment decline (OR: 0.994, 95% CI: [0.990 0.998]).

Conclusion

Economic downturns may marginally increase psychiatric help-seeking in EDs among publicly insured (low-income), working-age African Americans relative to white individuals. Findings from this study may contribute to the theoretical understanding of dynamic drivers of racial disparities in psychiatric ED visits.

External Validation of the SMART Medical Clearance Form for Emergency Patients With Psychiatric Manifestations

BACKGROUND

The SMART Medical Clearance Form, developed in the USA, is used to standardize the medical evaluation of emergency patients with primarily psychiatric manifestations. The goal of this study was external validation of the use of this form.

METHODS

Data were collected retrospectively on emergency patients with psychiatric manifestations. The combined primary clinical endpoint consisted of hospitalization, repeated presentation to the emergency room, and/or death within 30 days.

RESULTS

From September 2019 to June 2022, 2404 patients presented with psychiatric manifestations to the emergency room of the Cantonal Hospital of Lucerne, Switzerland, of whom 674 were included in the study. 134 did not satisfy any of the parameters of the SMART Medical Clearance Form (the nSMART group), while 540 satisfied at least one parameter (the pSMART group). In the nSMART group, there were no hospitalizations for a medical indication, no repeated presentations for medical reasons, and no deaths within 30 days. In the pSMART group, there were 90 hospitalizations, 4 repeated presentations, and 4 deaths within 30 days. Although 44% of the patients in the nSMART group underwent further diagnostic studies, such as imaging or laboratory tests, none of these studies led to any change in these patients' further clinical management.

CONCLUSION

Use of the SMART Medical Clearance Form apparently enables safe standardized processing of patients with psychiatric manifestations in the emergency room.

The significance of nonurgent psychiatric emergencies in an ED: a retrospective study

BACKGROUND

In emergency departments, patients with mental health conditions are a major concern and make up the third or fourth of the most common diagnosis seen during all consultations. Over the past two decades, there has been a noticeable rise in the number of cases, particularly due to an increase in nonurgent visits for somatic medical issues. The significance of nonurgent visits for psychiatric patients is yet to be determined. This study aims to uncover the significance and identify the characteristics of this group.

METHODS

A retrospective analysis of psychiatric emergency visits at an interdisciplinary emergency department of a German general hospital in 2015 was conducted. For this purpose, patient records were reviewed and evaluated. An analysis was conducted based on the German definition of psychiatric emergencies according to the German guidelines for emergency psychiatry.

RESULTS

A total of 21,124 emergency patients visited the evaluated Emergency Department. Of this number, 1,735 psychiatric patient records were evaluated, representing 8.21% of the total population. Nearly 30% of these patients did not meet any emergency criteria according to German guidelines. Significant differences were observed between previously treated patients and those presenting for the first time.

CONCLUSIONS

The high proportion of nonurgent psychiatric patients in the total volume of psychiatric emergency contacts indicates a possible control and information deficit within the emergency system. Just as prior research has emphasized the importance of investigating nonurgent somatic medical visits, it is equally imperative to delve into studies centered around psychiatric nonurgent presentations.

Effectiveness of a Self-Administered Computerized Mental Health Screening Tool in the Emergency Department

OBJECTIVE

The authors sought to determine the effectiveness of a self-administered computerized mental health screening tool in a general acute care emergency department (ED).

METHODS

Changes in patient care (diagnosis of a past-year psychiatric disorder, request for psychiatric consultation, psychiatric referral at discharge, or transfer to psychiatric facility) and patient ED return visits (3 months after discharge vs. 3 months before) were assessed among ED physicians (N=451) who received patients' computerized screening reports (N=207) and those who did not (N=244). All patients received copies of screening results.

RESULTS

The computerized mental health screening tool identified previously undiagnosed psychiatric problems. However, no statistically significant differences were found in physician care or patient ED return visits.

CONCLUSIONS

Computerized mental health screening did not result in further psychiatric diagnoses or treatment; it also did not significantly reduce patient ED return visits. Collaboration among EDs and mental health treatment agencies, organizations, and researchers is needed to facilitate appropriate treatment referrals and linkage.

Changes in emergency psychiatric consultations in time of COVID-19: a retrospective observational study in the Verona Academic Hospital over the two pandemic years 2020-2021

BACKGROUND

During the first months of the COVID-19 pandemic, local health authorities in most Italian regions prescribed a reduction of ordinary outpatient and community mental health care. The aim of this study was to assess the impact of the COVID-19 pandemic on access to the emergency departments (ED) for psychiatric consultation in the pandemic years 2020 and 2021 compared to 2019.

METHODS

This is a retrospective study conducted by using routinely collected administrative data of the two EDs of the Verona Academic Hospital Trust (Verona, Italy). All ED psychiatry consultations registered from 01.01.2020 to 31.12.2021 were compared with those registered in the pre-pandemic year (01.01.2019 to 31.12.2019). The association between each recorded characteristic and the year considered was estimated by chi-square or Fisher's exact test.

RESULTS

A significant reduction was observed between 2020 and 2019 (-23.3%) and between 2021 and 2019 (-16.3%). This reduction was most evident in the lockdown period of 2020 (-40.3%) and in the phase corresponding to the second and third pandemic waves (-36.1%). In 2021, young adults and people with diagnosis of psychosis showed an increase in requests for psychiatric consultation.

CONCLUSIONS

Fear of contagion may have been an important factor in the overall reduction in psychiatric consultations. However, psychiatric consultations for people with psychosis and for young adults increased. This finding underlines the need for mental health services to implement alternative outreach strategies aimed to support, in times of crisis, these vulnerable segments of the population.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document

The treatment of severe mental illness has undergone a paradigm shift over the last fifty years, away from a primary emphasis on hospital-based care and toward community-based care. Some of the forces driving this deinstitutionalization have been scientific and patient-centered, such as better differentiation between acute and subacute risk, innovations in outpatient and crisis care (assertive community treatment programs, dialectical behavioral therapy, treatment-oriented psychiatric emergency services), gradually improving psychopharmacology, and an increased appreciation of the negative effect of coercive hospitalization, except when risk is very high. On the other hand, some of the forces have been less focused on patient needs: budget-driven cuts in public hospital beds divorced from population-based need; managed care's profit-driven impact on private psychiatric hospitals and outpatient services; and purported patient-centered approaches promoting non-hospital care that may under-recognize that some extremely ill patients need years of painstaking effort to make a community transition. The result has been a reconfiguration of the country's mental health system that, at times, leaves large numbers of people without adequate mental health and substance abuse services. Often their only option is to seek care in medical emergency department's (ED's) that are not designed for their needs. Increasingly, many of those individuals end up waiting in ED's for appropriate care and disposition for hours or days. This overflow phenomenon has become so prevalent in ED's that it has been given a name: "boarding". This practice is almost certainly detrimental to patients and staff, and it has spawned efforts on multiple fronts to understand and resolve it. When considering solutions, both ED-focused and system-wide considerations must be explored. This resource document provides an overview and recommendations regarding this complex topic. Reprinted with permission from American Psychiatric Association. Copyright © 2019.

Factors predicting admission of psychiatric emergency contacts after presenting to the emergency department: results of a regression analysis

BACKGROUND

Psychiatric emergency patients have great relevance in the interdisciplinary emergency department. Emergency physicians in this setting often have to make decisions under time pressure based on incomplete information regarding the patient's further treatment. The aim of this study was to identify possible predictors associated with an increased likelihood of inpatient psychiatric admission.

METHODS

A retrospective cross-sectional study of all psychiatric emergency contacts in an interdisciplinary emergency department (ED) of a general hospital in a large German city was conducted for 2015. A binary regression analysis was performed to identify possible predictors.

RESULTS

In 2015, a total of 21421 patient contacts were reported in the emergency department, of which 1733 were psychiatric emergencies. Psychiatric emergency was the fourth most common cause presenting to the ED. The most common diagnosis given was mental and behavioral disorders due to the use of psychotropic substances (F1). Factors associated with an increased probability of inpatient psychiatric admission were previously known patients, patients under a legal care order (guardianship), and previous outpatient medical contact. No association for gender or age was found. Data demonstrated a negative relationship between a neurotic, stress-related and somatoform disorder diagnosis and admission.

CONCLUSIONS

The present study shows some significant characteristics associated with an increased likelihood of emergency admission. Independent of the health care system, the predictors found seem to be relevant with regard to the probability of admission, when compared internationally. To improve the treatment of patients in emergency units, these factors should be taken into account.

Do All Adult Psychiatric Patients Need Routine Laboratory Evaluation and an Electrocardiogram?

BACKGROUND

Acute psychiatric presentations account for a significant number of emergency department (ED) visits. These patients require assessment by the emergency physician and often need further evaluation by a psychiatrist, who may request routine laboratory evaluation and an electrocardiogram (ECG).

CLINICAL QUESTION

Do all adult psychiatric patients need routine laboratory evaluation and an ECG?

EVIDENCE REVIEW

Studies retrieved included 2 prospective, observational studies and 7 retrospective studies. These studies evaluate the utility of laboratory analysis in all patients presenting a psychiatric complaint and its impact on patient management and disposition.

CONCLUSION

Based upon the available literature, routine laboratory analysis and ECG for all patients presenting with a psychiatric complaint are not recommended. Clinicians should consider the individual patient, clinical situation, and comorbidities when deciding to obtain further studies such as laboratory analysis. © 2022 Elsevier Inc.

A quarter of century after: The changing ecology of psychiatric emergency services

INTRODUCTION

Previous studies demonstrated a trend of increasing common mental disorders among the Emergency Department (ED) visitors in Western countries. Little is known about the current conditions of the emergency psychiatric services in Asian countries. This study aims to survey the current epidemiology and the changing ecology of emergency psychiatry services in Taiwan.

METHODS

A total of 804 psychiatry consultations were initiated at the ED during the 1-year period from July 1, 2014 to June 30, 2015 in a medical center in northern Taiwan. Clinical data of gender, age, chief complaints, tentative diagnoses, dispositions, and ED staying hours were compared to a previous report in the same hospital in 1988.

RESULTS

Psychiatry consultation was initiated in 0.72% of all ED visits (804/111,923). Among these visits, females were 1.73 times of the males. The most common chief complaints were psychosis/mania (33.5%) and suicide/self-harm (33.2%), followed by homicide/violence (12.8%) and anxiety/depression (10.3%). Top tentative diagnoses were schizophrenia spectrum and other psychotic disorders (31.3%), trauma- and stressor-related disorders (17.5%), bipolar disorders (15.9%), and depressive disorders (14.2%). Compared to 1988, there are three major changes: (1) over-representation of female patients, (2) an increase of "neurosis" patients, and (3) an increase of suicide/self-harm as chief problem.

DISCUSSION

This study portrays the current epidemiology and changing ecology of psychiatric emergency in Taiwan. The increase of neurotic and suicide/self-harm patients requires more services and clinical training in managing common mental disorders and suicide in the ED.

Interpretable Identification of Comorbidities Associated with Recurrent ED and Inpatient Visits

In the hospital setting, a small percentage of recurrent frequent patients contribute to a disproportional amount of healthcare resource utilization. Moreover, in many of these cases, patient outcomes can be greatly improved by reducing re-occurring visits, especially when they are associated with substance abuse, mental health, and medical factors that could be improved by social-behavioral interventions, outpatient or preventative care. Additionally, health care costs can be reduced significantly with fewer preventable recurrent visits. To address this, we developed a novel, interpretable framework that both identifies recurrent patients with high utilization and determines which comorbidities contribute most to their recurrent visits. Specifically, we present a novel algorithm, called the minimum similarity association rules (MSAR), which balances the confidence-support trade-off, to determine the conditions most associated with re-occurring Emergency department and inpatient visits. We validate MSAR on a large Electronic Health Record dataset, demonstrating the effectiveness and consistency in ability to find low-support comorbidities with high likelihood of being associated with recurrent visits, which is challenging for other algorithms such as XGBoost. Clinical relevance- In the era of value-based care and population health management, the proposal could be used for decision making to help reduce future recurrent admissions, improve patient outcomes and reduce the cost of healthcare.

Strengthening Behavioral Health Services Through Partnerships and Data Integration

Background

There has been an increase in emergency medical service (EMS) use for behavioral health reasons. Detroit Wayne Integrated Health Network (DWIHN) and Detroit East Medical Control Authority (DEMCA) collaborated to study the rising number of behavioral health (mental disorders and substance use disorders) calls to EMS.

Methodology

To examine the trend, DWIHN and DEMCA partnered on a data-sharing project and identified that a high volume of EMS runs (responses by EMS as a result of an emergency call) involved individuals served by DWIHN.

Results

Over a period of 2.5 years, an average of one-third (33.73%) of EMS runs involved individuals who receive behavioral health services through DWIHN.

Conclusions

DWIHN used the data to create interventions and internal process improvements that can help coordinate medical and behavioral healthcare for individuals who have been using EMS increasingly. The findings were also used to develop prevention efforts to decrease the occurrence of such crises and to avoid unwarranted member involvement with the justice system. We suggest that other comparable organizations consider similar partnerships, especially given the increasingly high EMS and Emergency Department use for behavioral health reasons.

Characteristics of psychiatric comorbidities in emergency medicine setting and impact on length of hospitalization: A retrospective study

This study aims to evaluate clinical correlates of psychiatric comorbidity and length of hospitalization in patients admitted in a general hospital emergency medicine setting. Overall, 160 patients hospitalized for different acute medical pathologies were selected consecutively over 12 months. All subjects were evaluated with proper forms to collect data on medical and psychiatric diagnoses. Levels of C-reactive protein were also measured in all patients. Statistical analyses were conducted with univariate, logistic, and multiple linear regressions. Patients with psychiatric comorbidity had significantly longer hospitalization than did patients with no psychiatric diagnoses (days 10.9±9.5 vs. 6.9±4.5, p<0.005). Agitation and delirium were more frequent in the psychiatry comorbidity study group (p<0.05), as was cognitive impairment (p=0.001). These variables predicted longer hospitalisation (respectively: t=-3.27, p=0.002; t=-2.64, p=0.009; t=-2.85, p=0.006). Psychiatric comorbidity acts as an adjunct factor in determining clinical severity and predicting a more difficult recovery in patients hospitalized in an emergency medicine setting.

The Impact of Coronavirus Disease 2019 on US Emergency Departments

Behavioral emergencies in the United States have been increasing, with some studies reporting a doubling in the number of people experiencing symptoms related to mental health conditions, although overall visits to US emergency departments (EDs) decreased during the coronavirus disease 2019 (COVID-19) pandemic. The uncertainty surrounding the COVID-19 pandemic caused many people to avoid health care facilities, including EDs, even if they may have otherwise sought emergency care, and was associated with increases in new behavioral health diagnoses. Measures to limit the spread of COVID-19 led to people limiting their in-person contact with others, likely exacerbating preexisting mental health issues.

California Children Presenting to an Emergency Department for Mental Health Emergencies: Trajectories of Care

OBJECTIVES

Pediatric emergency department (ED) mental health visits are increasing in the United States. At the same time, child/adolescent psychiatric services are limited. This study examines the trajectory of pediatric patients presenting with mental health emergencies to better understand availability of specialty care resources in regional networks.

METHODS

This retrospective cohort study used a California Office of Statewide Health Planning and Development linked ED and Inpatient Discharge Dataset (2005-2015) to study pediatric patients (5-17 years) who presented to an ED with a primary mental health diagnosis. Outcomes were disposition: discharge, admission, or transfer.Patients transferred were further analyzed for disposition. Regression models to identify characteristics associated with disposition were created.

RESULTS

There were 384,339 pediatric patients presented for a primary mental health emergency from 2005 to 2015; 287,997 were discharged, 17,564 were admitted, and 78,725 were transferred. Among those not discharged, patients with public (odds ratio [OR], 1.28; P < 0.01) or self-pay insurance (OR, 5.64; P < 0.01), Black (OR, 2.15; P < 0.01), or Native American race (OR, 2.32; P < 0.01), and who presented to rural EDs (OR, 3.10; P < 0.01), nonteaching hospitals (OR, 3.06; P < 0.01), or hospitals in counties without dedicated child/adolescent psychiatric beds (OR, 5.59; P < 0.01) had higher odds of transfer.Among those not discharged from the second hospital, Black patients (OR, 2.47; P < 0.03) and those who were transferred to a teaching hospital (OR, 1.9; P < 0.01) had higher odds of second transfer.

CONCLUSIONS

Pediatric patients with mental health emergencies experience different trajectories of care. Transfer protocols and regionalized networks may help streamline services and decrease inefficiencies in care.

Characteristics of Pediatric Frequent Users of Emergency Departments in Alberta and Ontario

OBJECTIVES

Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada.

METHODS

Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models.

RESULTS

There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls.

CONCLUSIONS

Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.

Youth mental health-related presentations at a quaternary centre: Who comes, What are their needs, and Can we meet their needs

Background

Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services.

Objective

To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources.

Methods

We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility.

Results

Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month.

Conclusions

Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada

OBJECTIVES

Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group.

DESIGN

Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC.

SETTING

BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services.

POPULATION

All people age >15 with MSUD ED visits during the study period.

MEASURES

All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described.

RESULTS

A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care.

CONCLUSIONS

MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

A 7 Year Summary of Emergency Department Visits by Patients With Mental Health Disorders

OBJECTIVES

Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time.

METHODS

Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category.

RESULTS

Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits.

CONCLUSION

Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.

Transfer boarding delays care more in low-volume rural emergency departments: A cohort study

PURPOSE

Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals.

METHODS

A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas.

FINDINGS

A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs.

CONCLUSIONS

Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact.

Association between mood disorders and frequent emergency department use: a cross-sectional study

OBJECTIVES

Frequent emergency department (ED) use is a growing problem that is associated with poor patient outcomes and increased health care costs. Our objective was to analyze the association between mood disorders and the incidence of frequent ED use.

METHODS

We used the Canadian Community Health Survey conducted by Statistics Canada, 2015-2016. Mood disorder was defined as depression, bipolar disorder, mania, or dysthymia. Frequent ED use was defined as 4 or more visits in the year preceding the interview. Multivariable log-binomial regression models were used to determine the associations between mood disorders and frequent ED use.

RESULTS

Among the 99,009 participants, 8.4% had mood disorders, 80.3% were younger than 65, and 2.2% were frequent ED users. Mood disorders were significantly associated with the 1-year cumulative incidence of frequent ED use (RR = 2.5, 95% CI 2.2-2.7), after adjusting for several potential confounders.

CONCLUSIONS

This national survey showed that people with a mood disorder had a three-fold risk of frequent ED use, compared to people without mood disorder. These results can inform the development of policies and targeted interventions aimed at identifying and supporting ED patients with mood disorder.

The Impact of a New On-site Inpatient Psychiatric Unit in an Urban Pediatric Emergency Department

OBJECTIVE

The objective of this study was to describe the impact of opening an inpatient child psychiatric unit in an urban tertiary care pediatric emergency department (PED).

DESIGN/METHODS

A retrospective chart review was performed of pediatric patients seen in the PED at a large tertiary care center who presented for a primary psychiatric concern before opening of the inpatient psychiatric unit within the same hospital and 6 months following, allowing for a 6-month adjustment period. Patients were identified via query of the ED Cube model, an institutional database by a "behavioral health" flag that is documented in triage. Patients were excluded if subsequent chart review did not reveal a psychiatric concern and the patient did not undergo psychiatric evaluation during the PED visit. Charts were reviewed for baseline patient demographics, psychiatric interventions performed, and disposition. Additional flow metrics obtained were PED volume, percentage of psychiatric visits, and length of stay for both psychiatric-related visits compared with the general population.

RESULTS

Visits to the PED for psychiatric evaluation increased 135% from 91 to 226 after initiation of an inpatient psychiatric unit. There was no difference in baseline patient demographics or rate of medical/mechanical restraints used. Percentage of behavioral health patients admitted to medical units decreased, although overall admission rate remained stable. Length of stay for behavioral health patients was longer after opening of the unit and remained significantly higher than the general population before opening of the inpatient unit, 363 minutes versus 177 minutes, respectively, and further lengthened after to 418 minutes versus 188 minutes.

DISCUSSION

Patients presenting for psychiatric evaluation are a significant burden to PED flow both in volume and time for evaluation and boarding. This is to the detriment of patients seeking appropriate mental health services and to the rest of patients in the PED. Both inpatient and outpatient psychiatric services are overwhelmed creating a downstream affect; limited resources delays disposition and increases boarding in the PED. Further resources are needed to appropriately address psychiatric concerns, such as dedicated psychiatric holding units and brief PED interventions targeted to safety planning and interventions.

Urgent Psychiatric Consultations at Mental Health Center during COVID-19 Pandemic: Retrospective Observational Study

The coronavirus pandemic and related social distancing measures have brought about dramatic changes in people's lives. In particular, health workers have been forced to change their activities both for the different needs of patients and for preventive measures against the spread of the virus. This study is aimed at comparing the urgent psychiatric consultations (UPC) performed at the outpatient Mental Health Center (MHC) of Modena during the coronavirus outbreak period, from 1 March to 31 August 2020, with the same period in 2019. We retrospectively collected in a database the demographic and clinical characteristics of patients who required UPC in the MHC during the 6-month observation periods in both 2019 and 2020. Data were statistically analyzed. We analyzed 656 urgent psychiatric consultations in 2019 and 811 in 2020, requested by 425 patients in 2019 and 488 in 2020, respectively. In the pandemic period, we observed an increase in the total and daily number of UPC which were more frequently required by patients in care at local outpatient services in comparison with the previous period. During 2020, an increased number of UPC was carried out remotely and the outcome was more frequently represented by discharge at home, avoiding hospitalization as much as possible. In the course of the coronavirus pandemic, MHC had to face an increased demand for clinical activity especially from the most clinically and socially vulnerable patients, who more frequently required UPC in outpatient psychiatric services.

Public Health Surveillance of Behavioral Health Emergencies through Emergency Medical Services Data

Objective: To identify the demographic, clinical and EMS characteristics of events documented as behavioral health emergencies (BHE) by EMS. Methods: This was a cross-sectional study using the 2018 National Emergency Medical Services Information System (NEMSIS) Version 3 dataset. All events that had patient care provided with a documented impression (field diagnosis) of ICD-10 codes F01-F99 (i.e., mental, behavioral, and neurodevelopmental disorders) were labeled a BHE and included. Descriptive statistics were calculated. Results: A total of 1,594,821 (7.3%) EMS calls had a BHE impression. The most common was mental and behavioral disorders due to psychoactive substance use (42.3%). More males than females had BHEs (54.6% vs. 45.4%), and most patients were ages 18-34 (31.5%). Most BHE occurred in urban settings (89.6%). Almost half (47.9%) were dispatched with a complaint unrelated to behavioral health. Conclusion: BHEs were noted in 7.3% of NEMSIS events, and the majority were associated with substance use disorders. EMS professionals need comprehensive training on best practices for BHE. Stakeholders should have information on prevalence of BHEs to ensure proper educational standards, training practices, and resource allocation.

Receipt of Telepsychiatry and Emergency Department Visit Outcomes in New York State

Telepsychiatry has made psychiatric care more accessible to emergency department (ED) patients. To date, most telepsychiatry studies have focused on specific populations or small groups of EDs. This study sought to examine the potential role of telepsychiatry across a wider range of EDs by comparing visit dispositions for psychiatric visits in EDs that did (versus did not) receive telepsychiatry services. ED telepsychiatry service status was identified from the 2016 National ED Inventory-USA and then linked to psychiatric visits from the 2016 New York State Emergency Department Databases/State Inpatient Databases. Unadjusted analyses and multivariable logistic regression models were used to evaluate associations between an ED's telepsychiatry service status and two clinical outcomes: use of observation services and ED visit disposition. Across all psychiatric ED visits, 712,236 were in EDs without telepsychiatry while 101,025 were in EDs with telepsychiatry. Most (99.8%) visits were in urban EDs. In multivariable logistic regression models, psychiatric visits in EDs with telepsychiatry services had lower odds (adjusted odds ratio 0.30) of using observation services compared to visits in EDs without telepsychiatry. The receipt of ED telepsychiatry is associated with lower usage of observation services for psychiatric visits, likely reducing the amount of time spent in the ED and mitigating the ongoing problem of ED crowding. An overwhelming majority of visits in EDs with telepsychiatry services were in urban hospitals with existing psychiatric services. Factors affecting the delivery and effectiveness of telepsychiatry services to hospitals lacking in psychiatric resources merit further investigation.

10-Year Trends of Emergency Department Visits, Wait Time, and Length of Stay among Adults with Mental Health and Substance use Disorders in the United States

This study examined if there was a change in the number of Emergency Department (ED) visits, wait time, and length of stay among adults with mental health and substance use disorders (MHSUD) in the United States from 2006 to 2015. From the National Hospital Ambulatory Medical Care Survey, a total of 17,488 ED visits by adults with MHSUD were identified. Linear regression and negative binomial regression analyses were conducted to assess statistically significant changes in trends of ED visits, wait time, and length of stay. Results indicated that ED visits by adults with MHSUD increased by 30.6% from 2006 to 2015. Wait time of ED visits by adults with MHSUD decreased for the same time period; however, length of stay did not change. Also, there were some differences in trends of wait time and length of stay by diagnosis. Specifically, wait time of ED visits by adults with psychotic disorders did not decrease. Length of stay of ED visits by adults with anxiety disorders statistically significantly increased from 2006 to 2015. More effort is needed to improve the quality of ED care for adults with MHSUD. In such an effort, diagnoses should be taken into consideration.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan

Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

Prevalence of Cyberbullying in Patients Presenting to the Pediatric Emergency Department

OBJECTIVES

Mental health (MH) complaints are increasingly responsible for visits to pediatric emergency departments (PEDs). Bullying is associated with MH problems. Most adolescents use social media and many experience problems with cyberbullying (CB). This study determines prevalence of CB in MH and non-MH adolescents in a PED, describes technology use in these groups, and measures influence of CB on presentation to the PED and on thoughts/acts of self-harm.

METHODS

A prospective survey was administered to a convenience sample of 149 patients aged 11 to 17 years in a PED. Data were analyzed using descriptive and comparative statistical methods.

RESULTS

Cyberbullying was significantly more common in MH than in the non-MH patients (17% vs 3%, P = 0.007). More MH patients reported that bullying led to the current PED visit than that in the non-MH group (25% vs 10%, P = 0.02), and they were significantly more likely to report that CB led to self-harm (22% vs 4%, P = 0.003). Mental health participants who spent more than 3 hours on the Internet report higher levels of bullying than non-MH patients (38% vs 6%, P < 0.001).

CONCLUSIONS

Prevalence of bullying in MH patients presenting to a PED is significantly greater than controls, and CB caused more MH patients to have acts or thoughts of self-harm. Bullying is a risk factor for self-harm and suicide in patients with MH problems. Future studies should evaluate CB as part of suicide screening tools for emergency MH patients.

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015)

BACKGROUND AND OBJECTIVES

Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.

METHODS

We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.

RESULTS

From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.

CONCLUSIONS

The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

[The evolution of child psychiatry emergencies: Results and reflections from a Nancy University Hospital study]

INTRODUCTION

Mental illness is one of the most common causes of disability, morbidity and mortality in childhood. According to the scientific literature, the prevalence of mental health disorders is an estimated 10% to 20% in the USA and similar results are found in France. Although primordial, outpatient care often appears insufficient with inequalities in its geographical distribution and its accessibility. These past decades have been marked by an increase in consultations for mental disorders in pediatric emergency departments. Is this trend indicative of a "defect" in the healthcare organization? Identifying the root causes of this inflation in psychiatric consultations seems of paramount importance in the improvement of healthcare policies. In France and worldwide, only a few studies deal with this subject. That is why we proposed to observe the evolution of the number of consultations for mental health reasons in the pediatric emergency department of Nancy University Hospital and to detail their characteristics.

MATERIALS AND METHODS

Ancillary comparative and retrospective study (2003-2013) on minors having received a child psychiatry consultation within the pediatric emergency department of Nancy University Hospital.

RESULTS

The number of consultations for mental health reasons increased by 119% (97 in 2003; 212 in 2013), while consultations for pediatrics reasons remained stable over the period studied. Consultations mainly dealt with females representing 55.6% of consultations in 2003 and 63.7% in 2013. Mean age of consultants was stable: 13.9 years (standard deviation=3.3 years) in 2003; 14.1 (2.5) years in 2013. Family structure witnessed a three-fold increase in the single-parent model. Regarding consultation motives, behavioral disorders were significantly more represented in 2013: 27.7% (RR=1.7; 95% CI 1.0-2.8; P<0.05) versus 16.5%. As far as diagnosis is concerned (ICD-10), emotional and behavioral disorders increased to 35.9% from 12.6% (RR=2.8; IC95% 1.6-5.1; P=0.0001).

CONCLUSIONS

In France, as well as in other western countries, the number of visits in pediatric emergency departments for mental health reasons more than doubled over a 10-year span. This growth mostly concerned externalizing disorders as a motive for consultation. Causes for this increase are multifactorial and closely related to the prevalence of psychiatric disorders in children. Some studies showed that economic factors played a major role on mental illness during such a downturn as the financial crisis of 2007-2008. Unemployment caused by economic crises can weaken pediatric caregivers and therefore their patients. Evolution of family structure and value also explains this trend. These past decades, the two-parent model, relevant till the 1960s, has evolved to a point where single parents are more quickly overwhelmed. Family values are now focused on consensus rather than duty and hedonism has become a central value. Women are more involved in the working world which became for all a performance field. Several studies have shown that social settings where competitiveness is the norm breed externalized disorders in children by advocating short-term efficiency. Moreover, the widespread use of screens in households as well as early exposure impact the psychomotor development, decrease the amount of sleep and may be responsible for the occurrence of many psychiatric disorders. There are some epidemiological reasons too. In 1971, Omran introduced a concept called "epidemiological transition" explaining how mental health issues appeared in the limelight through to the decline of infectious and cardiovascular diseases. This phenomenon has already occurred in western countries which could explain the increase in the prevalence of psychiatric disorders. In Africa, there is evidence it may have already started. Beyond all these considerations, the increase in consultations for mental disorders in pediatric emergency departments can be explained by a change in care consumption habits. Going straight to the local emergency department, accessible on a 24/7 basis, is easier than waiting for an outpatient appointment and is also free for the have-nots lacking proper insurance coverage. Scarce resources in ambulatory care may also explain the increased recourse to emergency services. Several reports have shown a lack of child psychiatrists and their uneven geographical distribution. For example, in the US only a third of children with mental disorders receive proper care, a lack which doubled between 1997 and 2010. Despite the reason for this trend, it is important to propose a better fitting of the healthcare system to the population needs, and to improve prevention and early identification. All these changes require further collective reflection.

Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Trends in objectively measured and perceived mental health and use of mental health services: a population-based study in Ontario, 2002-2014

BACKGROUND

Mental illness is widely perceived to be more of a public health concern now than in the past; however, it is unclear whether this perception is due to an increase in the prevalence of mental illness, an increase in help-seeking behaviours or both. We examined temporal trends in use of mental health services as well as objectively measured and perceived mental health.

METHODS

We conducted a repeat cross-sectional study of Ontario residents who participated in Statistics Canada's Canadian Community Health Survey (2002-2014). We assessed temporal trends in objectively measured past-year major depressive episode (based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and International Classification of Diseases, 10th Revision) and past-month psychological distress (Kessler Psychological Distress Scale-6 score ≥ 8) and perceived, self-rated mental health. We also examined use of mental health services, including service use among those with a need for mental health care.

RESULTS

A total of 260 090 survey participants were included. The age- and sex-standardized prevalence of a major depressive episode (4.8%, 95% confidence interval [CI] 4.2%-5.3% in 2002 v. 4.9%, 95% CI 4.2%-5.7% in 2012; p = 0.9) and psychological distress (7.0%, 95% CI 6.3%-7.6% in 2002 v. 6.5%, 95% CI 5.7%-7.5% in 2012; p = 0.4) did not change significantly over time. However, self-rated fair or poor mental health status increased from 4.9% in 2003-2005 to 6.5% in 2011-2014 (p _trend < 0.001), as did the use of mental health services (7.2% to 12.8%, p _trend < 0.001). The percentage of individuals who had subjective or objectively measured mental health problems and did not access mental health services decreased significantly over time.

INTERPRETATION

Given the stable prevalence of objectively measured psychiatric symptoms, the increase in use of mental health services appears to be, at least partly, explained by an increase in perceived poor mental health and help-seeking behaviours.

The Utility of Serum Creatinine Kinase in Emergency Department Patients with Possible Substance-use Related Conditions

INTRODUCTION

Our goal was to assess the diagnostic utility and temporal kinetics of serum creatine kinase (CK) measurement as a predictor of acute kidney injury (AKI) in emergency department (ED) patients who present with possible substance-use related conditions.

METHODS

This was a retrospective chart review of ED patients with a urine drug screen (UDS) ordered and resulted between 2009-2013. Data was extracted electronically from EPIC Systems electronic health records, populated into a Microsoft Excel file, and includes demographics, chief complaint, vital signs, neuro-psychiatric physical examination findings, laboratory findings, psychiatric consult order time, ED medications given, orders, disposition and its time, and diagnosis.

RESULTS

Of 74,970 patients with an ED UDS, 22,101 (29%) had at least one CK measured. After inclusion and exclusion criteria, 2858 (13%) remained. Mean (standard deviation [SD]) age was 43.3 (12.5) years, 73% were male, 61% Black, 22% White, and 17% Hispanic. Mean (SD) ED length of stay was 10.4 (5.8) hours, and 56.7% were hospitalized. On average, CK was higher at 6-12 hours (p<0.001) and 12-18 hours (p=0.016) compared to 6 hours. CK was lower at 42-56 hours (p = 0.011), 72 hours (p<0.001), and over 72 hours (p<0.001), compared to 6 hours. Maximum CK was determined in those with >2 CK measures. We defined AKI risk as a creatinine of >1.4 milligrams per deciliter based on RIFLE criteria. AKI risk was calculated among those with at least two creatinine values in 522 patients. We identified five (1%) patients as having AKI risk. The odds of AKI risk were not associated with increase in CK over time.

CONCLUSION

In 74,970 ED patients undergoing UDS testing for potential substance abuse, there was no identifiable CK level associated with AKI risk. In patients with possible substance-use conditions, CK continued to trend up even after six hours from door time and began to decrease after 42 hours. We found no value in repeated ED CK measures. Disposition should not be based solely on CK levels.

Who Consult an Adult Psychiatric Emergency Department? Pertinence of Admissions and Opportunities for Telepsychiatry

Background and Objectives: Psychiatric disorders constitute frequent causes of emergency department (ED) admissions and these rates are increasing. However, referring to ED a whole range of conditions that could or should be dealt with elsewhere is imposing itself as a problematic situation. We aimed: (1) to provide a descriptive picture of the socio-demographic and diagnostic characteristics of the visits among adults at the psychiatric ED; (2) to estimate the clinical pertinence of these visits. Materials and Methods: Retrospective analysis of diagnostic/socio-demographic characteristics and clinical trajectories of patients admitted for a psychiatric condition at the adult psychiatric ED of the University Hospital of Geneva (HUG), Switzerland, during a 6-week timespan. Results: In our sample (n = 763 total admissions for psychiatric conditions; n = 702 for inclusion of patients having received a medical evaluation), depression/anxiety, suicidal behavior (SB), psychotic episode, and substance use disorder (SUD), in descending order, were the most common diagnoses for referral. Patients belonged to younger age groups (≤65 years), had a familial status other than married/in couple, and did not present an unfavorable socio-demographic profile. Concerning the pertinence for a psychiatric ED, primary diagnosis of depression/anxiety is the only variable significantly associated with different grade of degree. By the examination of the patients’ trajectory from admission to discharge, the clinical pertinence for a psychiatric ED admission existed for cases assigned to the Echelle Suisse du Tri (EST^®) scale degree 1 (corresponding to most urgent and severe conditions), particularly for diagnoses of depression/anxiety associated with SB, SB as primary or comorbid diagnosis, and psychotic and manic/hypomanic episode. However, diagnoses of depression/anxiety without urgent and severe features (degrees 2, 3, 4) constituted the most frequent mode of presentation. Conclusions: Ambulatory and community-integrated settings could be more appropriate for the majority of patients admitted to adult psychiatric EDs. Moreover, the implementation of telepsychiatry strategies represents a very promising opportunity to offer these patients care continuity, reduce costs and filter the demand for psychiatric ED.

A Systematic Review and Meta-Analysis of Personality Disorder Prevalence and Patient Outcomes in Emergency Departments

The objectives of this study were to perform a systematic review and meta-analysis of studies reporting prevalence of personality disorders (PDs) in emergency departments (EDs) and evaluate the effect of comorbid PDs on clinical outcomes. A systematic search of five databases along with manual searching and expert consultation was performed. A quality appraisal was conducted. A total of 29 articles were included. Prevalence of PDs in ED attendees varied depending on presenting complaint, Q(4) = 577.5, p < .01, with meta-analytic prevalence rates of suicide and self-harm at 35% and 22%, respectively. The assessment method had a significant effect on prevalence rates, Q(3) = 17.36, p < .01. Comorbid PD was a risk factor for repeating presenting complaint, subsequent ED return, and hospitalization. Better identification of PDs using screening tools in EDs could improve patient management and clinical outcomes. Future research should focus on PD prevalence in unselected ED populations using validated diagnostic interviews.

Children's Mental Health Emergency Department Visits: 2007-2016

BACKGROUND AND OBJECTIVES

Emergency department (ED) visits for children seeking mental health care have increased. Few studies have examined national patterns and characteristics of EDs that these children present to. In data from the National Pediatric Readiness Project, it is reported that less than half of EDs are prepared to treat children. Our objective is to describe the trends in pediatric mental health visits to US EDs, with a focus on low-volume, nonmetropolitan EDs, which have been shown to be less prepared to provide pediatric emergency care.

METHODS

Using 2007 to 2016 Nationwide Emergency Department Sample databases, we assessed the number of ED visits made by children (5-17 years) with a mental health disorder using descriptive statistics. ED characteristics included pediatric volume, children's ED classification, and location.

RESULTS

Pediatric ED visits have been stable; however, visits for deliberate self-harm increased 329%, and visits for all mental health disorders rose 60%. Visits for children with a substance use disorder rose 159%, whereas alcohol-related disorders fell 39%. These increased visits occurred among EDs of all pediatric volumes, regardless of children's ED classification. Visits to low-pediatric-volume and nonmetropolitan areas rose 53% and 41%, respectively.

CONCLUSIONS

Although the total number of pediatric ED visits has remained stable, visits among children with mental health disorders have risen, particularly among youth presenting for deliberate self-harm and substance abuse. The majority of these visits occur at nonchildren's EDs in both metropolitan and nonurban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care.

Retrospective Chart Review of Voluntary Admissions to an Inpatient Psychiatric Hospital in New York City: A Demographic Breakdown

The current paper evaluates psychiatric needs of voluntary admissions in a large urban psychiatric hospital through a retrospective chart review, as this research is limited within the United States. A total of 581 voluntary adult psychiatric admission charts were reviewed. Continuous variables were evaluated using an ANOVA while associations between variables were examined by an unadjusted Pearson correlation coefficient a stepwise linear regression analysis. Men were significantly more likely to have a past admission for psychiatric services (p = .016), suicidal ideation (p < .001) and test positive for substances (p < .001) than women, and were more likely to be unemployed, homeless and without insurance. Women were more likely to have a past suicide attempt and a depressive disorder. A significant relationship between gender and rationale for seeking voluntary admission (p < .001) was found. This study offers understanding of male and female voluntary admissions, and a foundation for improving treatment interventions to reduce recurrent readmissions.

Suicide and all-cause mortality in a high-risk cohort: A latent class approach

OBJECTIVE

To use latent class analysis to group patients consulted to an emergency psychiatry consultation service and assess occurrence of suicide attempts and all-cause mortality across groups.

METHOD

Latent class analysis was used to classify individuals assessed by psychiatry in the emergency department of the two teaching hospitals in Winnipeg, Canada. A second latent class analysis was done on individuals presenting with a suicide attempt. Indicators variables included a variety of clinically assessed factors, such as presentation suicidality and occurrence of anxiety/depression/psychosis, and prior medical treatment. Two post-treatment indicators were used; suicide attempt hospitalizations and all-cause mortality within 12 months of assessment.

RESULTS

Latent class analysis identified 8 classes for all presentations (n = 5292) and 3 classes for the attempter subgroup (n = 730). Although there is considerable overlap in indicators among the classes certain indicators differentiated between the groups: suicide attempt presentation, prior psychiatric treatment, psychotropic medication polypharmacy, childhood abuse, and addictions. Although the presence of deaths and future attempts varied between the identified groups, there were no groups with a >10% proportion of individuals with either of these outcomes.

CONCLUSIONS

Potential exists for latent class-based assessments, but additional samples with better indicators are needed.

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.

National trends in mental health-related emergency department visits by children and adults, 2009-2015

OBJECTIVES

Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits.

METHODS

Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis.

RESULTS

Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours.

CONCLUSIONS

Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Emergency department presentations with a mental health diagnosis in Australia, by jurisdiction and by sex, 2004-05 to 2016-17

OBJECTIVES

To examine trends in ED presentations with a mental health diagnosis (MH_dx ) in Australia by jurisdiction and by sex, between 2004-05 and 2016-17.

METHODS

Data were captured in the National Non-Admitted Patient Emergency Department Care Database. Outcomes were the proportion of ED presentations with a principal diagnosis of ICD-10-AM F00-F99 (MH_dx ), and the rate of all ED and MH_dx presentations per 10 000 population.

RESULTS

Between 2004-05 and 2016-17, MH_dx presentations experienced compounding annual growth of 5.9% nationally, and increased from 3.3% to 3.7% of all ED presentations with a diagnosis. Most growth occurred between 2010-11 and 2015-16. Northern Territory (NT) had the highest level of MH_dx presentations per 10 000 population, more than double the Australian average. The proportion of MH_dx presentations was highest in South Australia (SA) in most years, and the average annual proportion of MH_dx presentations was statistically significantly higher than the national average in SA, Queensland (QLD) and Western Australia (WA). The proportion of MH_dx presentations increased in each jurisdiction, with significant increases for Victoria, QLD, WA, Australian Capital Territory and NT. Males experienced greater numbers and rates of all ED and MH_dx presentations, while the proportion of MH_dx presentations was 8% higher for females.

CONCLUSIONS

The proportion of ED presentations for MH conditions, narrowly defined, has increased in all Australian jurisdictions between 2004-05 and 2016-17, but particularly since 2010-11. Differences between jurisdictions indicate jurisdictional specific issues. However, significant or upward trend of MH_dx presentations across all jurisdictions indicates generic issues necessitating concern and policy development at a national level.

Psychiatric-related Revisits to the Emergency Department Following Rapid Expansion of Community Mental Health Services

OBJECTIVES

Repeat visits (revisits) to emergency departments (EDs) for psychiatric care reflect poor continuity of care and impose a high financial cost. We test whether rapid expansion of community health centers (CHCs)-which provide regional, low-cost primary care-correspond with fewer repeat psychiatric-related ED visits (PREDVs).

METHODS

We obtained repeated cross-sectional time-series data for 7.8 million PREDVs from the State Emergency Department Database for four populous U.S. states (California, Florida, North Carolina, and New York) from 2006 to 2011. We specified as the outcome variable the count of repeat visits per ED visitor with a psychiatric diagnosis. We retrieved aggregate-level mental health visits at CHCs from the Uniform Data System. Negative binomial regression methods controlled for individual-level confounders, county health system and sociodemographic attributes, year fixed effects, and county fixed effects.

RESULTS

The risk of a repeat PREDV decreased with a county-level increase in mental health patients seen at CHCs (incidence rate ratio = 0.986, 95% confidence interval = 0.98 to 0.99). Conversion of this rate ratio to the number of revisits averted indicated 34,000 fewer repeat PREDVs in these four states statistically associated with a 1% expansion in CHC mental health visits. Exploratory analyses found that revisits decline for relatively mild/moderate illnesses (e.g., mood, anxiety disorders) but not for severe illnesses (e.g., schizophrenia/psychoses).

CONCLUSION

An increase in mental health services at CHCs corresponds with a modest decline in repeat PREDVs. This decline concentrates among those with less severe mental illnesses.

Acute interventions for aggression and agitation in psychosis: study protocol for a systematic review and network meta-analysis

INTRODUCTION

Individuals with psychosis may access emergency services due to aggression and agitation. When the de-escalation technique fails to achieve tranquillisation, several pharmacological options are available. However, evidence on which intervention to prefer in terms of efficacy and tolerability to achieve resolution of the acute episode (ie, rapid tranquillisation) of aggression and agitation is currently fragmentary.

METHODS AND ANALYSIS

We will include all randomised controlled trials comparing drugs or drug combinations or placebo for aggression or agitation episodes in adult individuals with psychosis. We will include individuals with psychosis (eg, schizophrenia and related disorders, bipolar disorder with psychotic symptoms, psychotic depression) but not substance or medication-induced psychosis or psychosis due to another medical condition. Our primary outcomes are the change in aggression or agitation scores within few hours since the administration of the intervention (efficacy outcome) and the proportion of participants who dropped out due to adverse effects (tolerability outcome). We will retrieve relevant studies from the register of studies of the Cochrane Schizophrenia Group. Also, we will run additional searches on CENTRAL, Embase and PubMed to retrieve potentially eligible studies focusing on other psychiatric diagnoses than those in the schizophrenia spectrum. We will conduct a random-effects network meta-analysis (NMA) for primary and secondary outcomes. In case of rare events of dichotomous outcomes, a common-effect Mantel-Haenszel NMA will be used instead. We will use the surface under the cumulative ranking curve and the mean ranks to rank all available treatments. Local and global methods of evaluation of inconsistency will be employed. Quality of evidence contributing to network estimates of the main outcomes will also be assessed with Confidence in Network Meta-Analysis.

ETHICS AND DISSEMINATION

This study does not require ethical approval. We will disseminate our findings by publishing results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019137945.

Mental and behavioural emergencies at a tertiary healthcare centre in India: Pattern and profile

Background

Sparse data are available on service utilization, pattern and profile of mental and behavioural emergencies in India. We explored the pattern and clinical profile of consecutively referred psychiatric emergencies at a premier tertiary healthcare centre in India.

Methods

We reviewed the consecutive referrals for acute mental and behavioural problems made by the emergency department and recorded in an emergency psychiatry register between January 2015 and January 2016.

Results

Over a 1 3-month period, 666 patients were assessed; of whom 473 (71 %) had no prior/known psychiatric history and 84 (12.6%) had a comorbid medical condition. Nearly one-third of patients had potential legal issues associated with their emergency. The most common reasons for presentation were: an attempt at self-harm (130; 19.5%), aggression/agitation ( 122; 18.3%) and psychoactive substance use-related problems (69; 10.3%). Schizophrenia and other psychotic disorders (89; 13.4%) and mood disorders (87; 1 3.1%) formed the 2 most common diagnostic groups seen in emergency. Most commonly prescribed medications were benzodiazepines (296; 44.4%) followed by antipsychotics (187; 28.1%) and antidepressants (90; 13.5%). Notably, 11% of patients (76) were advised immediate admission under psychiatry, half of whom could be admitted directly from the emergency.

Conclusion

Our findings suggest that there is a need to optimize emergency mental healthcare and develop service delivery models for common psychiatric emergencies in India.