EDs Need Processes for Transfer of Pediatric Mental Health Patients
By Stacey Kusterbeck
ED visits by children and adolescents with mental health disorders are unique in many ways, according to a recent report from the Centers for Disease Control and Prevention’s National Center for Health Statistics.1 The researchers wanted to provide updated estimates of ED use by children and adolescents with mental health disorders. “We also wanted to highlight differences in the use of ED by children and adolescents with and without mental health disorders,” says Loredana Santo, MD, MPH, the report’s lead author. Santo and colleagues analyzed data on ED visits from 2018-2021 from the National Hospital Ambulatory Medical Care Survey. Some key findings:
- Rates of mental health-related ED visits were higher among adolescents than children, and higher among females than males. (In contrast, rates for non-mental health visits were higher among children than adolescents, and similar among females and males).
- About one in five visits by patients with mental health disorders either were admitted to the hospital (9.2% of patients, compared to 4.7% for patients without mental health disorders) or transferred to a psychiatric hospital (12.4% of patients, compared to 0.3% of patients without mental health disorders).
- ED visits lasted four hours or more for 42% patients with mental health disorders (compared to 17.8% for patients without mental health disorders).
At Columbia University Irving Medical Center’s ED, lack of inpatient psychiatric beds and rising rates of adolescent depression and suicidality are top concerns, reports Lauren S. Chernick, MD, MSc, an associate professor of pediatrics in emergency medicine. Pediatric psychiatrists often help ED providers determine if the patient can contract for safety and be discharged home with a plan for outpatient follow-up. “If the contract for safety cannot be obtained, then we would move on to inpatient admission,” says Chernick. “But it could be days before we find a bed.”
Some EDs participate in daily rounds with the psychiatric, social work, and ED team to assess where things stand with each patient. “Relationship building can be very difficult. Every day there is a new resident, or each shift can bring a new doctor,” says Chernick.
The ED uses a tremendous amount of resources to ensure patients are safe while waiting for transfer to a psychiatric facility, adds Chernick. Often, parents cannot stay in the ED the entire time as a result of having other children or job responsibilities. Many patients require one-to-one observation during some or all the time they spend waiting for transfer. Even if patients are deemed safe for discharge with outpatient follow-up, it is not always possible to arrange those appointments. That becomes more difficult on weekends or off-hours shifts when staff who handle insurance are off. Also, many child psychiatrists have months-long wait lists, and many do not take insurance. “That is a huge barrier and creates extreme disparity between those who can afford it and those who cannot,” says Chernick.
For patients who require inpatient admission to a psychiatric facility, there are many obstacles to a successful transfer. Sometimes, a facility has an available bed, but the patient does not meet the criteria. Some psychiatric hospitals take only children under a certain age; others will not take patients with certain comorbidities (such as a depressed patient with diabetes) because the facility lacks capabilities to medically manage the patient. Sometimes, a bed is open, but the facility is too geographically far for the parents.
For ED providers, knowing the patient needs transfer but being unable to secure an inpatient psychiatric bed can be distressing. “Once we deem someone is fit for admission, and everyone’s in agreement, the families get appropriately frustrated at the wait time. And there’s nothing we can do as providers to make the time go any faster — it’s a very powerless feeling,” says Chernick.
ED providers may come back days later and find the patient is still in the ED waiting for transfer. “While the ED setting is not the ideal place for a depressed or suicidal child, we do the best we can to connect them to care and make sure they are safe while they are waiting,” says Chernick.
Depending on how many psychiatric patients are waiting for transfer at a given time, one designated ED provider might care for some or all the psychiatric patients. “It gets really difficult to go back and forth between psychiatric patients and other patients, and maintain patient flow,” says Chernick. “Providers need mental space to focus on patients, and we work hard to maintain a high level of care for all our patients.”
- Santo L, Peters ZJ, Davis D, et al. Emergency department visits related to mental health disorders among children and adolescents: United States, 2018-2021. National Health Statistics Reports. Published Oct. 24, 2023. https://www.cdc.gov/nchs/data/nhsr/nhsr191.pdf
ED visits by children and adolescents with mental health disorders are unique in many ways, according to a recent report from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
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