Pediatric psychiatric cases are coming in record numbers: Don't risk tragedy

Many EDs report doubling and tripling’ of pediatric psychiatric patients

A man screaming in pain after a motor vehicle accident. A 12-year-old boy who has just attempted suicide. Which patient will get your attention first?

In the ED, the needs of psychiatric patients often are pushed aside to address life-threatening emergencies such as traumatic injuries and heart attacks, says Jacqueline Grupp-Phelan, MD, MPH, assistant professor of pediatrics for the division of emergency medicine at Children’s Hospital Medical Center in Cincinnati. "An airway issue is going to take precedence over a child who is acutely psychotic, because we have to deal with the patient most likely to have a bad outcome," she says.

However, children with psychiatric emergencies are coming to EDs in rapidly increasing numbers, so you must be prepared to care for these patients, says Grupp-Phelan.

Children's Hospital Medical Center is part of a large network of pediatric hospitals, and the facilities have seen doubling and tripling of psychiatric emergencies, she reports.

Last fall, the ED at Children’s National Medical Center in Washington, DC, was treating about 50 children with psychiatric emergencies per month, according to Lisa M. Ring, RN, MSN, CPNP, advanced practice specialist for the emergency medicine and trauma center. "Our current numbers are 150-200 children per month," she reports.

At least 200,000 children with psychiatric problems are seen in EDs each year, according to a 2002 study.1 Reasons include decreased numbers of inpatient beds and lack of access to mental health providers, says Grupp-Phelan.

To make sure that children with psychiatric emergencies are given appropriate care, you’ll need to find creative solutions, she says. "We may not have gone into emergency medicine to deal with psychiatric issues, but nationally there are as many visits for mental health problems as for asthma," Grupp-Phelan says. "So whether we like it or not, we have to gear ourselves up for this."

To improve care of children with psychiatric emergencies, use these effective strategies:

Develop a protocol.

The following protocol for pediatric psychiatric patients is being developed at her ED, says Ring: Once a child is identified in triage as having a psychiatric emergency, a complete medical examination will be given. If the child is determined to be medically stable, he or she will go to a separate area in close proximity to the ED, staffed with an administrative assistant, a psychiatric technician, and a social worker.

"With this system, families will be provided with a dedicated psychiatric staff to meet their unique needs," says Ring.

Currently, these children are triaged, examined, and receive a psychiatric consult, all in the main ED, she says. "We have only one consult room, so we often use our observation unit for overflow," she explains.

Evaluate the child’s safety.

Children may not use the words you expect regarding suicide, so you must ask probe further if their intent is unclear, says Deby Campbell, RN, MSN, clinical nurse specialist for the pediatric ED at Banner Desert Medical Center in Mesa, AZ.

"For example, the response I recently got from a 12-year-old girl was, What difference does it make if I’m not hanging around?’"

When Campbell asked the girl if she was considering hurting herself, the child said emphatically that she "didn’t mean it that way," and added, "There are too many great things to live for."

"I was comfortable that she was upset, crying, and fighting with her mother, but she wasn’t considering suicide," says Campbell. Obtain the history from the patient first in private and then from the parents, she says. "This builds trust with the patients that you are caring for them," Campbell says.

Perform the assessment out of the earshot of others, she stresses. "Listen to the child in private, just like you would any other patient," Campbell says. Even if you already were given a history by a parent or pre-hospital provider, never forget to do a thorough head-to-toe assessment, says Campbell. "Assess for airway, breathing, and circulation changes secondary to an ingestion, and also look for bruising, slash marks, or hidden knives in shoes," she instructs.

Don’t make promises you can’t keep about what you will share with the child’s parents about substance abuse or pregnancy, says Campbell. "I tell the patient that it would be best for them to tell their parents, but I will stay in the room if they would like me to be there," she says.

If the patient answers "yes" when you ask if he or she intends to harm him or herself, the next step is to then ask for more specifics, says Campbell. "If I ask, Do you have a plan?’ and the response is No, not really,’ that tells me they are reaching out for help," she says.

If the child does have a plan, you need to assess the potential for acting upon it, and consider any previous attempts, she says.

If a child has harmed him or herself, Campbell recommends asking, "What did you expect to happen?" or "What did you want to feel?" Responses vary widely, from "I wanted my boyfriend to be sorry and make up with me," to "I wanted to die," she says.

Ensure that children receive follow-up care.

Although you need to assess safety while a child still is in your ED, a decision also must be made as to whether the patient needs to be admitted or can go home, says Grupp-Phelan.

"A system needs to be set up so we can make sure we aren’t sending kids home who are at high risk for suicide," she says.

If you don’t feel there are adequate resources to meet the child’s social and medical needs, inpatient admission may be the only alternative, says Grupp-Phelan.

"We need to be able to sleep at night after we see these patients, and we are absolutely strapped by what is in our community, in terms of follow-up support," she says.

You must know exactly what resources exist in your community, says Grupp-Phelan. "In the ED, we really need to understand what is available and what we can access," she stresses. "Every community has resources, and you need to understand what yours are."

It helps to have a nurse or social worker in your ED who can help link families to available follow-up care, says Grupp-Phelan. That individual also should be knowledgeable about insurance issues, she adds.

"Unfortunately, that is the biggest stumbling block," she says. "So that individual ends up being an insurance technician’ in addition to being able to assess the psychiatric needs of a child."

Invite nurses to become experts.

Most ED nurses are experienced in caring for abused or neglected children, whose complex social and medical needs mirror those of psychiatric patients, notes Grupp-Phelan. "We have care structures in the ED for children with those problems, so there is a good model already in place," she says.

Sexual assault nurse examiners (SANEs) are another example of nurses who can assess a patient’s medical and social needs and link them with follow-up services, says Grupp-Phelan. "These are regular ED nurses who have decided this is an important issue, and they want to be specially trained," she says.

Similarly, ED nurses could be trained to evaluate children with psychiatric emergencies, she suggests.

"If nurses are able to resuscitate a kid and do SANE nursing at the same time, it’s not a far leap to think they could do this as well," says Grupp-Phelan. "There could be a cadre of specially trained nurses in each ED."

Reference

1. Melese-d'Hospital IA, Olson LM, Cook L, et al. Children Presenting to Emergency Departments with Mental Health Problems. Acad Emerg Med 2002; 9:528-a.

Resources

For more information on caring for children with psychiatric emergencies, contact:

Deby Campbell, RN, MSN, Pediatric Emergency Department, Banner Desert Medical Center, 1400 S. Dobson Road, Mesa, AZ 85202. Telephone: (480) 512-3349. Fax: (480) 512-5312. E-mail: Deby.Campbell@bannerhealth.com.

Jacqueline Grupp-Phelan, MD, MPH, Assistant Professor of Pediatrics, Division of Emergency Medicine, OSB-4, Children’s Hospital Medical Center, Cincinnati, OH 45229. Telephone: (513) 636-3465. Fax: (513) 636-7967. E-mail: Jackie.Grupp-Phelan@cchmc.org.

Lisa M. Ring, RN, MSN, CPNP, Advanced Practice Specialist, Emergency Medicine & Trauma Center, Children’s National Medical Center, 111 Michigan Ave. N.W., Washington, DC 20010-2970. Telephone: (202) 884-4865. E-mail: Lring@cnmc.org.

A report titled Mental Health Treatment for Self-Injurious Behaviors: Clinical Practice Guidelines for Children & Adolescents in the Emergency Department (product No. 000706) gives model clinical practice guidelines for emergency care providers confronted with self-injurious behavior including suicide, substance abuse, and intentional self-destructive behavior. The cost is $2.20 per copy plus $3.50 for shipping. The report can be ordered from the Emergency Medical Services for Children (EMS-C) web site (www.ems-c.org). Click on "Products & Publications," "EMS-C Product Catalog," and "Product Order Form." Or contact the EMS-C Clearinghouse, 2070 Chainbridge Road, Suite 450, Vienna, VA 22182. Telephone: (703) 902-1203. Fax: (703) 821-2098. E-mail: emsc@circlesolutions.com. Web: www.ems-c.org.