Pediatric Corner

Don't miss emergencies in 'challenging' teens

Psych complaints are rising

"More and more" preteen and adolescent patients are coming to the Emergency Department Trauma Center at Children's Hospital of Wisconsin in Milwaukee with a variety of psychosocial needs, and many have underlying medical conditions as well, says Carrie L. Baumann, RN, BSN, patient care supervisor.

Joyce Fuss, RN, BSN,CEN, FNE, a senior partner nurse in the ED at Methodist Hospital in Indianapolis, is seeing an increasing number of adolescents with psychological problems. "I believe this is due to the decreased availability of community resources," says Fuss. "Since psych is not a money maker, more and more facilities are having to cut back. This leaves the ED to figure out what is best for these patients."

Fuss says that she is seeing an increasing number of this population without parents. "Many of the adolescents we see are parents themselves," she adds.

Privacy is key

Adolescent patients often fail to tell ED nurses important clinical information, warns Baumann.

"They will withhold pregnancy status, sexual activity, drug and alcohol history, and social/family history," she says. "Triage may not be the appropriate area for personal questions. Privacy is your key to getting the most accurate information."

Fuss agrees that your patient should be interviewed alone. "Many times, active listening is the key to getting all the information needed," she says. "Treat them like you would an adult. Give all the information to them, allowing the parents to listen if appropriate."

Speaking directly to the patient, instead of their parents, builds trust, says Fuss.

Trauma easily could be missed if the patient is out of control, combative, and has a psychiatric history, notes Fuss. "So could ingestions, if the patient does not state they took something," she adds.

Fuss says that it is "very difficult to get patients who are having true psychiatric breaks calm. When they are, they require medications that sedate them. Sedated patients are difficult to interview to determine the cause of the problem."

Risk of self-harm

Fuss says that in her experience, "the adolescents who state they are going to harm themselves while making a big scene rarely do so on purpose. Many times, they do something they feel will get them attention. They do not understand that the end result may be fatal," she adds.

The patients who Fuss has seen do intentional harm to themselves are most often "the quiet ones who have a flat affect and are withdrawn from everyone. Many times, you can talk the dramatic patient down quickly. The withdrawn one will tell you what you want to hear so they can continue on with their plan."

To improve the care of "challenging adolescents," Baumann's ED has made these changes:

• Screening questions are asked.

Before the patient even arrives at triage, he or she is greeted and screened by an ED nurse who can contact social workers or place the patient in a private screening room. "This is integral in quickly assessing the situation and starting the ball rolling," says Baumann.

• Local inpatient facilities are consulted as needed.

"There is a crunch for space in the current facilities that take our psychiatric patients," explains Baumann. "We do not have an inpatient psychiatric unit, so we depend on outside resources."

ED nurses work with social services, and in some cases local law enforcement, to facilitate a patient's transfer to outside facilities. "This decreases length of stay in the ED and gets them the help they need," says Baumann.

If the patient is discharged from the ED, parents are informed about outside resources such as support groups, adds Baumann. "Our social workers hand out multiple resources to parents to help them to cope with having a child with mental and psychosocial issues," she says.

• An outreach nurse contacts each patient that was seen in the ED.

This ED nurse asks if there are any problems with paperwork sent to a facility, difficulties with medications, or if any additional phone numbers are needed.

"Mostly, they are a support for the parents. They make sure that next steps are being taken," says Baumann. "This decreases repeat visits to the ED."

Sources

For more information on caring for adolescents with psychiatric complaints, contact:

  • Carrie L. Baumann, RN, BSN, Emergency Department Trauma Center, Children's Hospital of Wisconsin, Milwaukee. Phone: (414) 266-4768. E-mail: CBaumann@chw.org.
  • Eileen Callahan, RN, BSN, Pediatric Nurse Educator, Emergency Department, Tufts Medical Center and the Floating Hospital for Children, Boston. Phone: (617) 636-9649. E-mail: ecallahan@tuftsmedicalcenter.org.
  • Joyce Fuss, RN, BSN, CEN, FNE, Senior Partner, Emergency Medicine Trauma Center, Methodist Hospital, Indianapolis, IN. Phone: (317) 962-8355. E-mail: jfuss@clarian.org.

Is bullying occurring? Ask direct questions

Screen all children in the ED

ED nurses at Tufts Medical Center and the Floating Hospital for Children in Boston have always performed pediatric safety screening, including car seat and seat belt use, fall risk, secondhand smoke exposure, and suicidality. Now, nurses have begun asking questions about bullying.

When Eileen Callahan, RN, BSN, one of the ED's pediatric nurse educators, was caring for a 12-year-old with complications from her diabetes, she learned that the girl had been ostracized at school by other children who thought "they could catch diabetes by being near me." "The bullying became so severe, the child needed to change to another school," says Callahan.

She formed a task force to discuss bullying screening in the ED. "We met to discuss what our plans would be if we had a positive bullying screen from a pediatric patient," Callahan says. "We are presently in the process of putting together a formalized algorithm of how we would respond." This is the ED's current process:

• ED triage nurses tell pediatric patients, "We are checking all school age children who come into the ED to make sure they are safe at school."

"We then ask if they have ever been bullied or if they are being bullied at school now," says Callahan.

If the answer is yes, ED nurses ask the parent or guardian if it has been reported to the school. "If it has been reported, we encourage the family to stay on top of the school to ensure the child's safety. We notify the primary care doctor to ensure the mental health of the child," says Callahan.

• ED physicians perform a brief psychiatric screening to see if the child is in imminent danger of self-harm.

A 12-year-old girl came to the ED significantly withdrawn, and ED nurses learned this condition was due to bullying. "We did a physical and mental health evaluation in the ED. She was admitted to a child psych facility for further treatment," says Callahan.

If there are concerns about the child harming him or herself, ED nurses contact child psychiatry to evaluate the patient while still in the ED. "If the child has mental health issues, but does not appear to be at risk of imminent danger, we refer them to our child psychiatry outpatient department for close follow-up," says Callahan.

• Families are encouraged to file a report with the school if they have not already done so.

Callahan cared for a 10-year-old boy who had been nauseous and vomiting for nine days, and she learned that he had had problems with bullying. "The child looked quite well physically, and blood work did not show any sign of dehydration," says Callahan. "It was determined that some of the abdominal complaints may be attributed to his bullying at school."

ED nurses notified the child's primary care physician. "She was happy to have been informed of this information and planned to have close follow-up with the family," says Callahan.