Management of youth with suicidal ideation: Challenges and best practices for emergency departments

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

Review of pediatric emergency care and the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic posed new challenges in health care delivery for patients of all ages. These included inadequate personal protective equipment, workforce shortages, and unknowns related to a novel virus. Children have been uniquely impacted by COVID-19, both from the system of care and socially. In the initial surges of COVID-19, a decrease in pediatric emergency department (ED) volume and a concomitant increase in critically ill adult patients resulted in re-deployment of pediatric workforce to care for adult patients. Later in the pandemic, a surge in the number of critically ill children was attributed to multisystem inflammatory syndrome in children. This was an unexpected complication of COVID-19 and further challenged the health care system. This article reviews the impact of COVID-19 on the entire pediatric emergency care continuum, factors affecting ED care of children with COVID-19 infection, including availability of vaccines and therapeutics approved for children, and pediatric emergency medicine workforce innovations and/or strategies. Furthermore, it provides guidance to emergency preparedness for optimal delivery of care in future health-related crises.

Pediatric diabetes: management of acute complications in the emergency department

Children with diabetes mellitus are at high risk for acute life-threatening complications of their chronic disease. Identification and management of these emergencies can be complex and challenging. This issue provides guidance for recognizing pediatric patients with new-onset diabetes as well as diabetic crises in established patients. The most recent literature is reviewed and an approach to managing emergent diabetic complications in the pediatric patient is provided, with a focus on initial stabilization and management. Key features in treating pediatric patients with hyperglycemic emergencies are discussed, including rapid fluid resuscitation when indicated, initiation of insulin, and addressing complicating comorbidities.

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

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Resources for Improving Pediatric Readiness and Quality of Care in Rural Communities and Emergency Departments

OBJECTIVES

To share the process and products of an 8-year, federally funded grant from the Health Resources and Services Administration Emergency Medical Services for Children program to increase pediatric emergency readiness and quality of care provided in rural communities located within 2 underserved local emergency medical services agencies (LEMSAs) in Northern California.

METHODS

In 2 multicounty LEMSAs with 24 receiving hospital emergency departments, we conducted focus groups and interviews with patients and parents, first responders, receiving hospital personnel, and other community stakeholders. From this, we (a regional, urban children's hospital) provided a variety of resources for improving the regionalization and quality of pediatric emergency care provided by prehospital providers and healthcare staff at receiving hospitals in these rural LEMSAs.

RESULTS

From this project, we provided resources that included regularly scheduled pediatric-specific training and education programs, pediatric-specific quality improvement initiatives, expansion of telemedicine services, and cultural competency training. We also enhanced community engagement and investment in pediatric readiness.

CONCLUSIONS

The resources we provided from our regional, urban children's hospital to 2 rural LEMSAs facilitated improvements in a regionalized system of care for critically ill and injured children. Our shared resources framework can be adapted by other regional children's hospitals to increase readiness and quality of pediatric emergency care in rural and underserved communities and LEMSAs.

Multicenter Retrospective Review of Adult Patients Presenting to Pediatric Emergency Departments: Impact of Interfacility Distance

OBJECTIVE

This descriptive study aimed at evaluating the impact of distance between a general and pediatric emergency department (PED) on adults seeking care at PEDs.

METHODS

The Pediatric Health Information Systems database was used to perform a retrospective study of all adult patients presenting to PEDs from 2005 to 2015. Data regarding age, disposition, pregnancy status, insurance status, median household income, all-patients refined diagnosis-related groups, and procedures were gathered. Distances were categorized as PEDs less than 1 mile and 1 mile from a general facility. Data were analyzed for the entire population, in addition to those 45 years old.

RESULTS

The majority of patients were discharged from the ED; transfers were more frequent at PEDs 1 mile away from a general facility. Death was rare, with minimal differences noted between interfacility distances (21: 0.25% vs 0.24%; 45: 0.36% vs 0.32%). Cardiopulmonary resuscitation occurred in 0.25% with no differences based on location. Pregnant women visits and childbirth occur more frequently in PEDs closer to general facilities (4.89% vs 2.85%, P < 0.05; 0.07% vs 0.03%, P < 0.05, respectively). Chest pain was seen more frequently at PEDs located farther away from general EDs, the difference more pronounced in those 45 years old (21: 5.12% vs 6.3%; 45: 6.61% vs 13.17%).

CONCLUSIONS

Statistically significant differences were seen in the adult population presenting to PEDs based on the interfacility distance between a pediatric and general ED. These data can help PEDs prepare for the adult patients they are more likely to treat.

Management of pediatric transplant patients in the emergency department

Transplant patients are at risk for illnesses and complications days, months, or years after transplantation, and they can present complex challenges for emergency clinicians. This review discusses the general approach to the management of pediatric transplant patients in the emergency department, with a focus on general complications and organ-specific complications after solid organ transplantation. Hematopoietic stem cell transplantation and its common complications will also be discussed. A key step in the management of all transplant patients includes consultation with the patient's transplant team to ensure appropriate testing, treatment, and disposition for these patients.

High-flow nasal cannula and noninvasive ventilation in pediatric emergency medicine

The use of high-flow nasal cannula and noninvasive ventilation has become increasingly common in emergency medicine as a first-line treatment of pediatric patients with respiratory distress secondary to asthma and bronchiolitis. When implemented in clinical practice, close monitoring of vital signs and ventilation parameters is warranted to identify possible signs of respiratory failure. This issue provides evidence-based recommendations for the appropriate use of noninvasive ventilation modalities in pediatric patients including high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure in the setting of acute respiratory distress. Contraindications and complications associated with these modalities are also discussed.

Pediatric Readiness in the Emergency Department

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage is a frequent occurrence in the emergency department, and management of potentially life-threatening and ongoing bleeding by the emergency physician is challenging. Limited evidence-based guidelines exist, and practice patterns vary widely. We administered nebulized tranexamic acid to achieve hemostasis in a pediatric patient with associated bleeding cessation prior to definitive operative management.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Molecular organization of a recombinant subviral particle from tick-borne encephalitis virus

The tick-borne encephalitis (TBE) flavivirus contains two transmembrane proteins, E and M. Coexpression of E and the M precursor (prM) leads to secretion of recombinant subviral particles (RSPs). In the most common form of these RSPs, analyzed at a 19 A resolution by cryo-electron microscopy (cryo-EM), 60 copies of E pack as dimers in a T = 1 icosahedral surface lattice (outer diameter, 315 A). Fitting the high-resolution structure of a soluble E fragment into the RSP density defines interaction sites between E dimers, positions M relative to E, and allows assignment of transmembrane regions of E and M. Lateral interactions among the glycoproteins stabilize this capsidless particle; similar interactions probably contribute to assembly of virions. The structure suggests a picture for trimer association under fusion-inducing conditions.