Many EDs are seeing a dramatic surge in children with psychiatric complaints, a group that is clinically challenging and presents some serious legal risks.

“Patients with psychiatric conditions are at risk of injuries, either from attempts at self-harm, impulsive behaviors, or injuries inflicted by others,” says Genevieve Santillanes, MD, an associate professor of clinical emergency medicine at the University of Southern California in Los Angeles. The authors of multiple recent studies have discovered a pattern of slowly increasing rates of pediatric psychiatric patient visits to EDs over the past decade.

One in 10 ED visits by children and young adults (ages 6 to 24 years) in 2015 were for psychiatric reasons, according to a recent analysis.1 The researchers found a 28% increase in psychiatric ED visits between 2011 and 2015 (with the largest increases among adolescents, African Americans, and Hispanics).

Fifty-one percent of visits lasted at least three hours, and 20% of visits took more than six hours. Despite spending that long in the ED, most patients never saw a mental health provider during the visit. Only 37% of adolescents who attempted suicide or self-injury, and 16% of all psychiatric patients, saw a mental health provider in the ED.

In an analysis of COVID-19 pandemic data, researchers found the proportion of mental health-related ED visits for children ages 5 to 11 years and adolescents ages 12 to 17 years increased 24% and 31%, respectively, between March and October 2020 compared to the same period one year earlier.2

The number of pediatric ED visits was stable from 2007 to 2016, but visits for mental health disorders rose 60% during that period. Visits for deliberate self-harm rose 329%, according to data from the National Pediatric Readiness Project.3 Notably, most of these visits were at general EDs as opposed to pediatric EDs.

The Children’s of Alabama ED saw 219 children age 10 years and younger with a mental health complaint in the first half of 2016.4 Of this group, 45% were admitted. Three or more previous psychiatric diagnoses, family history of psychiatric illness, history of trauma or any previous psychiatric care, and chief complaints of suicidal ideation all raised the odds of admission.

When caring for pediatric psychiatric patients, EDs face specific liability risks:

The pediatric patient may harm themselves or another person, either after discharge or in the ED. “While patients are being held in the ED, [staff] must ensure that the patient is adequately supervised and that their space is free from potential means to harm themselves or others,” Santillanes explains.

ED providers may miss an attempt at self-harm. “Emergency physicians should always consider whether a work-up for potential toxic ingestions is necessary in patients with depression or suicidal ideation,” Santillanes suggests.

A patient may deteriorate because of a concurrent medical condition. Plaintiff attorneys can argue the condition was unaddressed during a long ED stay, or that the condition was not adequately stabilized before transfer to a psychiatric facility.

“This includes known medical conditions, such as diabetes or seizure disorders, or unrecognized conditions, such as infections,” Santillanes adds.

ED providers may attribute the patient’s signs and symptoms to a psychiatric condition when, in fact, the findings are caused by an underlying medical disorder. “This may occur with initial presentation of a psychiatric mimic,” Santillanes says.

For example, a patient with anti-NMDA receptor encephalitis might be misdiagnosed with a psychiatric condition and inappropriately transferred to a psychiatric hospital instead of being admitted to a medical bed for treatment.

Concurrent medical conditions could lead to worsening of patients’ chronic mental health conditions, particularly in those with communication difficulties. “Patients with autism, particularly nonverbal patients, may have increased aggression or self-harming behaviors when they are in pain,” Santillanes notes.

A careful physical exam and history might reveal contributory medical conditions such as constipation or appendicitis. “It is also critical to ensure that symptoms that seem to be psychiatric in nature truly are due to psychiatric conditions, and not medical conditions such as encephalitis, neurologic disorders, or metabolic derangements,” Santillanes cautions.

Before pediatric psychiatric patients are discharged from the ED, Santillanes says staff should carefully document the visit. This includes recording that there was an evaluation of risk factors and protective factors as well as notes about possible access to lethal means of suicide (e.g., firearms and medications).

It also is important to create a follow-up plan with a primary care physician or mental health professional. For patients presenting with suicidal ideation, a social worker or mental health clinician should develop a safety plan (including removing lethal means of harm, listing recognition of triggers, identifying coping mechanisms, and recording a list of people who can help if symptoms worsen).

Finally, before these patients are discharged, document any resources, such as phone numbers for emergency contacts, that were provided, and indicate that a clinician screened for abuse. “Children with histories of trauma, including abuse, may present with psychiatric or behavioral emergencies,” Santillanes says.

There also is the potential for EMTALA issues, such as failure to stabilize concurrent medical conditions. “There is a need to ensure that the patient is medically stabilized prior to any admission or transfer to a behavioral health unit or facility,” says Mary C. Malone, JD, a partner at Hancock Daniel in Richmond, VA.

Another EMTALA concern is whether it is OK for pediatric patients to be transferred via private car. “To ensure a safe transfer as required by EMTALA, it is better to have a medical transport with a parent riding along, if desired,” Malone offers.

Pediatric psychiatric patients tend to be left in the ED for long periods because there are no available inpatient beds. This is legally problematic for several reasons. “The risk is that the same patient is being signed out multiple times, crossing over three or four shifts before you can get a disposition on them,” says Alfred Sacchetti, MD, chairman of the department of emergency medicine at Our Lady of Lourdes Medical Center in Camden, NJ.

If the patient is agitated or aggressive, providers may end up chemically sedating them. “Then, you run into all of the problems that go along with that — is it too much, is it too little?” Sacchetti says. “You hate to physically restrain a child because there are all kinds of negative implications there.”

Sometimes, the child is sedated when the ED finally receives a call back from telehealth after a long wait. The telehealth provider then instructs the ED to allow the medications to wear off before giving a consult. “Then, you have an agitated child again. It can become a vicious cycle,” Sacchetti observes.

EDs often lack immediate access to crisis personnel, psychiatry, or social services. If so, says Sacchetti, “telehealth can give you direction in terms of sedation, and in terms of disposition.”

Sometimes, telehealth can arrange outpatient follow-up for the patient. “That is the best thing. That can mitigate a lot of your risk because now you’ve got a formal consultant helping out with the case,” Sacchetti says.

Certain patients do need to be admitted, but many hospitals have closed their pediatric services.5 “They really have nowhere to put the patient,” Sacchetti laments.

But some agitated patients, or a patient with Asperger’s or a patient on the autism spectrum, can receive adjusted medication doses and improve during the ED visit. If within 24 hours they are back to baseline, the ED can discharge the patient with a plan for follow-up care. “In the time it takes looking for the inpatient bed, they may get well enough to go home,” Sacchetti reports.

This is similar to when asthmatic patients who are boarded in EDs receive nebulizer treatments and are well enough to go home before an inpatient bed becomes available. “It may not be medications. It may just be sessions talking to the telepsychiatrist,” Sacchetti offers.

Telehealth consults are well-recognized as equivalent to in-person consults. “There’s been enough data out there that it works effectively,” Sacchetti says.

At times, the closest in-person consult may be hundreds of miles away, necessitating a transfer. Telehealth can prevent the need to transfer the child. “Telehealth can come up with a plan. It is very reasonable for the EP to feel much more comfortable discharging that patient because of that,” Sacchetti adds.

REFERENCES

  1. Kalb LG, Stapp EK, Ballard ED, et al. Trends in psychiatric emergency department visits among youth and young adults in the US. Pediatrics 2019;143:e20182192.
  2. Leeb RT, Bitsko RH, Radhakrishnan L, et al. Mental health-related emergency department visits among children aged < 18 years during the COVID-19 pandemic — United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675-1680.
  3. Lo CB, Bridge JA, Shi J, et al. Children’s mental health emergency department visits: 2007-2016. Pediatrics 2020;145:e20191536.
  4. Read K, Schwartz J, Martinez J, et al. Characterization of young children presenting to the emergency department for mental health complaints. South Med J 2020;113:116-118.
  5. Chang WW. The rapidly disappearing community pediatric inpatient unit. The Hospitalist. July 12, 2018.