ED care of peds psych patients is inconsistent
A child's race and ethnicity is irrelevant when it comes to treatment of pediatric psychiatric patients, correct? Not necessarily, according to a new study, which found that minority children are more likely to receive severe mental health disorder diagnoses in the ED than white children.1
Researchers looked at records of 2,991 patients from a pediatric psychiatric ED over a one-year period, and they found that 4.5% of African-American and 4.9% of Hispanic/Latino children and teens were given diagnoses of psychotic disorders, compared with only 2.5% of white children and teens. Also, only 34.9% of white children and teens received diagnoses of behavioral disorder, compared with 50.3% and 46.4% of African-American and Hispanic youth, respectively.
As an ED nurse, you have a "central role in reducing mental health disparities," says Jordana Muroff, PhD, LICSW, the study's author and assistant professor at Boston University's School of Social Work. She recommends giving ED nurses inservices on cultural considerations in the clinical decision-making process, with attention to interviewing skills and the diverse populations being served by the ED.
Scott Phillips, RN, clinical nurse leader at All Children's Hospital in St. Petersburg, FL, says, "The pediatric psych patient is hard to deal with in any situation. But the ED nurse can make the difference in every situation."
Give consistent care
The pediatric psychiatric patients often come in "waves" through the Emergency Center at All Children's Hospital in St. Petersburg, FL, reports Misty N. Eiler, RN, BSN, clinical nurse leader. "We tend to see more during the school year related to peers, workload, or conflicts with parents related to their activities."
First identify any emergent symptoms such as altered mental status, difficulty breathing, or statements that the child intends to, or has, harmed himself or herself. "This will determine triage status," says Eiler.
After the patient is brought back to a room, the primary nurse does a secondary evaluation and obtains a more extensive medical history. This assessment includes:
- overall appearance — whether the child looks disheveled;
- speech characteristics;
- eye contact;
- general behavior with or without parents;
- interaction with staff;
- previous history.
"It is fairly uncommon for a pediatric patient to have been diagnosed with psychiatric illnesses other than ADHD [attention deficit hyperactivity disorder]," says Eiler. Unless a parent states that the child or adolescent has ingested medication, other underlying medical conditions must be considered. Ask these questions:
- Has the child recently had an accident and bumped his or her head? "This could be causing confusion and disorientation," she says.
- Has the child recently been vomiting? "The dehydration may be causing an electrolyte imbalance," says Eiler.
"Many of these conditions can be ruled out by a head CT or basic lab work," she says. If these results are negative, you might need to order urine drug screen, acetaminophen, and salicylate levels.
"We sometimes have ingestions that come in by EMS [emergency medical services]. When they return to baseline, we can then determine if it was an intentional overdose or recreational drug use," says Eiler. "A social work evaluation is always done for these kids as well."
- Muroff J, Edelsohn GA, Joe S, et al. The role of race in diagnostic and disposition decision making in a pediatric psychiatric emergency service. Gen Hosp Psychiatry 2008; 30:269-276.