BACKGROUND AND OBJECTIVES: Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non–mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits. METHODS: We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005–2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression. RESULTS: From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non–mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69–4.44); there was no difference in LOS by payer type. CONCLUSIONS: The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

https://pediatrics.aappublications.org/content/pediatrics/early/2021/04/02/peds.2020-030692.full.pdf

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015).

Importance The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services Objective To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs) Design, setting, and participants Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts Exposures Presentation at an ED Main outcome and measure A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report Results The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [630%]; mean [SD] age, 151 [161] years) with 3-month follow-ups (729% retention [2075 adolescents]) The study 2 validation sample included 2754 adolescents (1711 female adolescents [621%]; mean [SD] age, 150 [165] years), with 3-month follow-ups (695% retention [2754 adolescents]) The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 089 [95% CI, 085-091]) in study 1 The mean number of adaptively administered items was 11 (range, 5-21) At a specificity of 80%, the CASSY had a sensitivity of 83% It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 087 [95% CI, 085-089]) In this study, the CASSY had a sensitivity of 824% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1 Conclusions and relevance In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services

Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed. 

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Advocacy to Address Emergent Pediatric Mental Health Care

Maintaining Safety and Improving the Care of Pediatric Behavioral Health Patients in the Emergency Department

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Maintaining Safety and Improving the Care of Pediatric Behavioral Health Patients in the Emergency Department