Expect repeat ED visits from pediatric psych patients

Just because a child with mental health issues is connected with an outpatient provider doesn’t mean he or she won’t come to the ED frequently for care, according to research from Johns Hopkins Children’s Center.1

Of 2,900 children treated for a mental health crisis in the ED over an eight-year period, 12% had a repeat ED visit within six months. Of the 338 patients with at least two visits to the ED, two-thirds reported having an outpatient mental health provider.

Children with mental health issues may come to the ED for many reasons, says Emily Frosch, MD, the study’s lead author and director of education and training for the Division of Child & Adolescent Psychiatry at Johns Hopkins Medicine in Baltimore.

"Even if they don’t need to be hospitalized, and it’s nothing imminently dangerous, there are definitely times when they need help and support," says Frosch.

Don’t discourage patients

"There is no doubt, with the economy and cutbacks in community health, that more kids are surfacing in EDs," says Ann Moore, director of the inpatient psychiatric unit at Seattle (WA) Children’s Hospital, who supervises the ED’s mental health specialists. "Family anxiety is going up, and the ability to pay for services is going down."

A child may end up in the ED because the family is feeling overwhelmed, because outpatient care is unavailable during off hours, or because schools won’t allow a child to return until a mental health evaluation is completed, says Denise Downey, RN, MSN, CPEN, nurse educator for emergency services at Children’s Hospital Boston.

"We never discourage any patient from returning to the ED with concerns," she says. "This includes our mental health patients and their families." To reduce repeat ED visits, use these practices:

Give patients a list of resources.

"Be sure the parent leaves with something in hand. The more concrete and tangible the information is, the better," says Frosch. "Circle which resource to call first, and which one to call second." A mobile crisis unit may be available to come to the home or school, says Frosch, for example, that the family is unaware of.

Frosch suggests calling a 24-hour hotline while the patient is still in the ED to arrange follow-up for the next day, or making a clinic appointment for the patient. "Dial the number and hand them the phone," she says.

Informing mental health patients about available resources, says Frosch, "is no different from instructing an asthma patient on how to use a nebulizer. The more you review it, the more likely they are to use it correctly."

Have a designated ED nurse be the "go to" person for children with mental health issues.

"This patient population isn’t for everybody. Some people really enjoy it, and others really don’t," says Frosch. "Ideally, there would be at least one person per shift for ED nurses to ask questions of."

If your hospital has psychiatric services, ask the department to give in-services to emergency nurses.

"Nurse managers in the ED and psychiatric services could do cross training," Frosch suggests. (See related stories on important questions to ask and tips to improve care, below.)

Reference

  1. Frosch E, dosReis S, Maloney K. Connections to outpatient mental health care of youths with repeat emergency department visits for psychiatric crises. Psychiatric Services 2011;62:646-649.

Sources

For more information on caring for pediatric psychiatric patients in the ED, contact:

  • Denise Downey, RN, MSN, CPEN, Nurse Educator, Emergency Services, Children’s Hospital Boston. Phone: (617) 355-6611. E-mail: denise.downey@childrens.harvard.edu.
  • Emily Frosch, MD, Director, Education & Training, Division of Child & Adolescent Psychiatry, Johns Hopkins Medicine, Baltimore. Phone: (410) 955-4298. E-mail: efrosch@jhmi.edu.
  • Mary M. Pelton, RN, CEN, Emergency Department, Carteret General Hospital, Morehead City, NC. Phone: (252) 723-3773. E-mail: mmpelton@CCGH.org.
  • Amy Truog, RN, BSN, CPEN, Staff Nurse, Level II, Emergency Services, Children’s Hospital Boston. Phone: (617) 355-6611. E-mail: amy.truog@childrens.harvard.edu.

Clinical Tip

Ask why patient came back to ED

Was a pediatric patient previously seen in your ED for the same mental health issues he or she is presenting with today? If so, explore the reasons for this, advises Denise Downey, RN, MSN, CPEN, nurse educator for emergency services at Children’s Hospital Boston. Downey says to get answers to these questions:`

  • What time of the day did the patient return to the ED? Is it off hours?
  • Did the patient have transportation for appointments?
  • Were the appointments convenient?
  • Did the patient or parent communicate with the outpatient program before coming to the ED?
  • Has the patient had the first outpatient visit yet?
  • What is the relationship with the outpatient provider and the patient? Does the family have confidence in the outpatient provider, or are they seeking a "second opinion"?
  • Is the patient able to obtain his or her medications? Is he or she compliant?

"Address the responses to these questions as they arise," Downey says.


Use these tips for pediatric psych patients

If a child or adolescent presents with a psychiatric complaint, ask him or her "What have you been diagnosed with?" advises Mary M. Pelton, RN, CEN, an ED nurse at Carteret General Hospital in Morehead City, NC.

"I have found that despite the age, from 5 and up, they know their diagnosis and treatment plans," says Pelton. "If you ask them, What caused you to be brought to the ED today?’ they will tell you fairly directly." She gives these tips to improve your assessment:

Be direct.

"These patients know the vernacular, and are very familiar with the process," says Pelton. "You do not have to sugar coat it for them in the least."

Be consistent in your process.

"This is probably the most important thing the ED staff can do when dealing with any psychiatric patient, but especially the pediatric patient," says Pelton.

For instance, she says, ED nurses on the night shift cannot allow patients to have their cell phones, while day-shift nurses do enforce the rule against having cell phones.

Obtain a medication list to be sure the patient isn’t missing doses.

"Losing days in the ED awaiting placement without receiving their routine medication is a recipe for escalation," says Pelton.

Keep patient safe

"Provide and maintain patient safety, until the patient is either discharged, admitted, or transferred to a proper facility," says Amy Truog, RN, BSN, CPEN, staff nurse level II in the emergency department at Children’s Hospital Boston. Truog says that these steps are taken:

  • Assess the patient’s suicide risk.
  • If the nurse is concerned for patient safety, flight risk, or homicidality, initiate a 1:1 patient safety watch and escort the patient to a "safe" room.
  • Conduct a patient search with the patient’s consent, unless there is reasonable cause to believe that the patient is harboring a weapon.
  • Use the acronym HALT (H = hungry, A = angry, L = lonely, T = tired/thirsty) to assess possible reasons for the patient’s escalating behavior.

"Often, escalating behavior is caused by patients feeling any of the above, and can be diverted by offering food, drink, conversation, or a safe activity," says Truog.