The current state of mental health services in Canada’s paediatric emergency departments

Abstract

OBJECTIVE:

To describe emergency mental health services in major paediatric centres across Canada.

METHODS:

A cross-sectional study of mental health services in emergency departments (EDs) from all 15 Canadian tertiary care paediatric centres was conducted.

RESULTS:

Fifteen individuals participated and were either a paediatric emergency physician with administrative responsibilities (60%) or an emergency mental health care provider (40%). Four participants reported that their ED used an evidence-based guideline, tool or policy, and one participant reported their ED based its services on published research evidence. Reported ED-based mental health resources included a crisis intervention team (five EDs), a mental health nurse (six EDs) and a social worker (five EDs). Thirteen participants reported on-site consultation with child psychiatry and six reported urgent follow-up as an adjunct service to ED care.

CONCLUSIONS:

There is a wide variety of mental health care practices in Canadian paediatric EDs. Consideration of which resources are required to ensure evidence-based, effective services are provided to children and youth is necessary.

There has been a recent increase in the number of emergency department (ED) presentations in Canada and the United States for paediatric mental health concerns (1,2). EDs are increasingly becoming the first, and sometimes only, point of access for care for many families struggling to manage their child’s mental health needs (3,4). Several studies have pointed to an increase in nonurgent presentations as opposed to merely higher prevalence rates of mental health issues (2,4–6), which suggests that some families may be using EDs due to a lack of awareness or availability of other community-based mental health services (4).

In Canada, a key barrier to paediatric mental health care is the absence of a national, unifying child and youth mental health policy framework to inform clinical care protocols, guidelines and health care tools (7). Recent available data suggest that Canada is not yet one of the 14 countries that meets the criteria for national policies that recognize the unique mental health problems of children and adolescents (8). A Canadian study comparing practices used in a paediatric ED with those used in a psychiatric-resourced ED demonstrated that comprehensive management of child mental health was lacking in both settings (9). Given these limitations in the health care landscape, a better understanding of current practices and the existing resources available for mental health care in paediatric EDs across Canada is needed to identify the strengths and gaps of current services. The present study describes existing ED protocols, guidelines and processes related to emergency mental health care from Canada’s 15 tertiary paediatric centres.

METHODS

Study setting, population and survey methodology

A cross-sectional study of children’s emergency mental health services for every tertiary care paediatric centre across Canada (n=15) was conducted from November 2009 to January 2010. Pediatric Emergency Research Canada (PERC), a research network that is involved with each of these paediatric centres, approved and facilitated the present study. PERC site representatives were contacted by e-mail to provide contact information for the individual responsible for mental health protocols and guidelines for each ED, the individual involved in their creation, or, if those individuals did not exist in the ED, for an individual who was the most knowledgeable with regard to the protocols, guidelines and processes in place for the assessment, treatment and referral of children and youth who present with mental health concerns. The University of Alberta Health Research Ethics Board (Edmonton, Alberta) approved the present study.

To optimize the response rate, a full Dillman approach was used (10,11), with weekly invitations and reminders regarding study participation sent via e-mail for up to three weeks. Each participant was mailed an envelope to submit relevant department protocols/guidelines regarding mental health services. Following protocol/guideline submission, participants completed a telephone-based clinical practice survey.

Data collection

Protocol/guideline review:

Two team members independently reviewed each ED protocol/guideline before the telephone interview. One team member extracted relevant protocol/guideline data (the protocol/guideline name including type of care involved and date of last update) using a standardized abstraction form, and the second member verified data abstraction for completeness by reviewing abstracted data against the original protocol/guideline. Discrepancies were resolved by consensus with a third team member. Abstracted data were used to tailor questions asked in the telephone interview.

Telephone interview:

A clinical practice survey was developed by members of the research team (Appendix 1) for the telephone interviews. The survey was based on the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) instrument (12; developed to assess clinical practice guidelines) and was reviewed for face and content validity and feasibility before use. The final survey contained 18 questions under the following domains: scope and purpose, stakeholder involvement, rigour of development, clarity, presentation and applicability, and overall assessment. The front end of each question was tailored if the protocols/guidelines were submitted by the participant (eg, What is the overall objective of the [protocol/guideline]?). In EDs where no formal or written protocols/guidelines existed, participants were asked to comment on informal protocols/guidelines using the clinical practice questions to structure the discussion. Each interview was audio recorded to facilitate data collection and ensure data accuracy; interview notes were also written. Interviews were conducted by one team member who also transcribed the interview data into a standardized spreadsheet based on the clinical practice survey questions. Data entry was reviewed for completeness and clarity by a second team member who listened to the audiotape recordings while reviewing the spreadsheet entries. Discrepancies were resolved by consensus with a third team member.

Data analysis

Participants’ responses to the clinical practice survey were summarized using simple counts (frequency distributions and means were calculated using SPSS version 16.0 [IBM Corporation, USA] for Windows [Microsoft Corporation, USA]) or are presented verbatim (in the case of open-ended survey questions).

RESULTS

Respondent demography

The present study’s response rate was 100%, with representation from each of Canada’s tertiary care paediatric centres. Participants were from eight provinces: British Columbia (n=1), Alberta (n=2), Saskatchewan (n=1), Manitoba (n=1), Ontario (n=5), Quebec (n=3), Nova Scotia (n=1) and Newfoundland (n=1). Survey participants tended to be men (60%) and were paediatric emergency physicians with administrative responsibilities (60%) or emergency mental health care providers (40%) (eg, child psychiatrist or other mental health care provider).

Paediatric emergency mental health care service availability

The delivery of paediatric emergency mental health care varied across the country. Five participants reported that the ED they worked in had a team devoted to children’s mental health care. Clinical care models, roles (team membership) and service coverage are summarized in Table 1. Eleven participants reported having a mental health nurse or social worker available for emergency mental health care. Thirteen participants reported that their ED had child psychiatrists available for consultation on site and two participants indicated that consultation was accessed through off-site resources (eg, resources in another hospital). Six participants reported that their ED had urgent follow-up (post-ED care) as an adjunct service to ED care. Urgent follow-up models are presented in Table 2. Only four participants indicated that the ED where they worked used a formal guideline, tool or policy to guide clinical care and processes.

TABLE 1.

Clinical care models for paediatric mental health care available in five of 15 Canadian paediatric emergency departments (EDs)

In ED

Clinical care begins following triage; triage determines if patient is to be seen by a mental health professional (nurse, social worker) or emergency physician (if medical stabilization required). If a mental health professional is seen:

Model 1: Provide problem-focused care to diffuse the crisis (additional to assessment and referrals, disposition recommendation, admission/discharge)

Model 2: Mental health assessment, risk assessment, recommendations (referrals, disposition, admission/discharge)

A psychiatrist or psychologist is consulted when necessary

Coverage varied across sites: 24/7 (model 1); M–F 07:30 to 23:30, S/S on-call 08:30 to 16:00, on-site 16:00 to 24:00 (patients arriving after 23:30 held until morning for assessment) (model 2); M–F 08:00 to 23:00 (model 2)

Outside of ED

Mental health care responsibilities were divided among urgent follow-up clinic, ED and inpatient unit.

Team: psychiatrist, child/youth counsellor, nurse practitioner, social worker

Coverage: In ED, treat emergent cases 09:00 to 17:00 M–F. On call until 23:00

24/7 Twenty-four hours a day, seven days a week; M–F Monday through Friday; S/S Saturday and Sunday

TABLE 2.

Urgent follow-up models available in six of 15 Canadian paediatric emergency departments (EDs)

Clinic-based

Clinic offers two to three daily spots for children or youth requiring follow-up within 48 h of a crisis. No designated team: Consists of psychiatrist and residents. No funding to support dedicated mental health staff M–F coverage; 1 h spot for emergency assessments: ED physicians or social workers refer for assessment Provide description of ‘urgent’ and ‘emergent’ needs that community partners follow closely. Have a protocol for ‘threat assessment’ in schools; schools follow protocol before triaging the child or youth to emergency services Clinic does not accept referrals from ED (must have physician name on referral to refer back to). ED physicians need to refer families to their family physician for referral to the clinic Service by psychiatrists includes acute assessment and referral back to the family physician with recommendations on management Clinic offers assessment within 48 h for nonemergent visits to ED; appointments are booked by the ED physicians directly without assessment from the crisis team

Mobile

‘Mobile team’ offers follow-up: may either come in to see the patient in the ED at the time of presentation (during evenings or weekends when no other ED mental health coverage) or will follow up with the patient as an outpatient within 48 h. Offer assessment, consultation, intervention and stabilization services ‘Response team’ offers follow-up postdischarge within 24 h (M–F 08:00 to 16:00). Set up community resources or psychiatry referral if urgent issues evident.

M–F Monday through Friday

Paediatric emergency mental health care service development

The process described by participants for developing ED mental health care services (guideline/protocol/clinical care model) is presented in Table 3. Thirteen participants reported that local and clinical experience or evidence was used to inform service development. ED physicians represented the majority stakeholders in the development of these practices (10 hospitals). The majority of participants were not aware of evaluations that had been performed for ED mental health care service development. Sixty per cent (nine of 15) of participants reported not knowing whether a pilot evaluation had been performed when the service had been developed; these individuals were not involved in protocol/guideline creation, and there was no documentation of whether this evaluation took place at protocol/guideline inception. Fifty-three per cent (eight of 15) of participants were unsure whether an external evaluation had been conducted for ED services since they had been implemented. For these participants, the evaluation had been performed during their tenure in the ED, and they were hesitant to state whether one had been conducted before their involvement. Procedures for reviewing and updating processes varied but were mainly driven by department (ED) and/or interdepartment (ED and psychiatry) meetings (46.7%).

TABLE 3.

Children’s mental health emergency department (ED) protocol/guideline/service development in Canada’s 15 paediatric EDs

Stakeholder involvement*	n (%)
ED physicians	10 (66.7)
ED nurses	6 (40.0)
ED mental health staff: social workers, mental health nurses, crisis team	5 (33.3)
Child psychiatry	6 (40.0)
Patients/families	1 (6.7)
Community partners (school board, mental health agencies)	1 (6.7)
None	1 (6.7)
Unknown	4 (26.6)
Information sources
Published research evidence	1 (6.7)
National/international recommendations	0 (0)
Government policy	1 (6.7)
Local, clinical experience/evidence	13 (86.7)
Internal pilot evaluation
Yes	1 (6.7)
No	3 (20.0)
Unknown	9 (60.0)
External evaluation
Yes	0 (0)
No	7 (46.7)
Unknown	8 (53.3)
Procedure for reviewing/updating processes*
Department/interdepartment team meetings	7 (46.7)
Interagency meetings	1 (6.7)
Hospital or government policy driven	2 (13.3)
No	2 (13.3)
Unknown	4 (26.6)

^*Total is >100% because some EDs reported more than one development aspect

Clarity, presentation and applicability of paediatric emergency mental health care protocols/guidelines/processes

Nine participants reported that their mental health care protocols/guidelines/processes were specific and unambiguous, and 10 participants reported that their approach to mental health management/care was clearly presented in their ED’s protocol/guideline. When asked to identify and describe organizational barriers to children’s mental health ED services in their hospital, participants identified funding, access to services and long wait times as barriers. Other barriers included the limited number of available spaces for non-acute patients in follow-up clinics, the limited mental health coverage in EDs because of short staffing hours, and the lack of inpatient psychiatry. Participants also identified strict access criteria to urgent follow-up as a barrier because it forces the family to return to their family physician to get a referral for an urgent clinic assessment. Others stated negative repercussions had occurred for ED clinical care processes following changes made in children’s mental health divisions (eg, psychiatry). One participant stated that the hospital administration’s belief that the burden of disease is less in children compared with adults was a major barrier to developing and offering paediatric mental health ED services.

DISCUSSION

While the increasing demand for emergency mental health services in EDs has been documented (2,13), there is no study, to our knowledge, that has examined the availability of mental health services for children in Canada and the process involved in developing these services. In the present study, we found that the structure and process of children’s emergency mental health care varied among paediatric EDs. Services spanned a broad range, from problem-focused, crisis-based care to mobile response teams. The range of services reported likely reflects the different stakeholders and processes involved in their development, and emphasizes the need for national policies to guide service development and evaluation and to promote resource allocation (8).

The majority of participants in the present study indicated that the mental health services currently offered in paediatric EDs were not evidence-based. Furthermore, most participants were not aware of evaluations that had been performed (or are in place) to evaluate services, and the procedures for reviewing and updating protocols/guidelines/processes varied, but did not necessarily involve a formal evaluation. These results suggest that few procedures exist to determine the effectiveness of the services currently being offered to Canadian children and youth, and that reviews and service updates should include a formal evaluative component. As such, our understanding of the ED services available to children and youth with mental health emergencies is undermined by the lack of evidence of their therapeutic value. Leading Canadian child and youth agencies have already identified this knowledge gap as an important issue that needs to be addressed (8).

It has been suggested that medical resource unavailability can significantly affect the outcome of intervention efforts (14). For paediatric mental health care, the unavailability of paediatric mental health protocols/guidelines/processes could significantly affect child mental health outcomes. To this effect, formulation of evaluation plans, the development of quality indicators for clinical practice and regular monitoring of currently available mental health services in EDs is necessary to identify important objective markers of success and areas for service improvement. For some facilities, these markers may be child, parent and provider satisfaction. For others, it may include evaluating the impact of the support on clinical and health system outcomes, such as the reduction in clinical symptomatology or time to a follow-up appointment. One such Canadian-based evaluation exists for a rapid-response outpatient follow-up for suicidal adolescents, which included the examination of postservice hospitalization rates, patient functioning and symptomatology (15).

The present study also draws attention to the varied composition of the interdisciplinary teams that provide mental health services to children and youth. At this time, however, we do not know the effect that the composition and location of these teams (ED versus follow-up clinic) have on child or youth health outcomes and use patterns. A recent systematic review demonstrated that availability of a psychiatric team was instrumental in the reduction of the number of hospitalizations, shifted triage scores and improved wait times in some cases (16). However, additional research is required to confirm the necessity and impact of a specialized team in the context of paediatric EDs.

On a final note, the majority of participants in the present study indicated that they were satisfied with the services provided, because they believed that their mental health processes were specific and unambiguous and that their approach to mental health management/care was clearly presented in their guidelines. This may suggest a general belief that there are no major problems in the services EDs provide and that this positive evaluation poses a potential barrier to the potential changes needed in paediatric mental health emergency care. The present study’s findings also confirm previous studies’ conclusions by listing common barriers such as fragmented health care delivery, long wait lists, shortage of staff and lack of communication with management (8). Although these issues and barriers have been reported elsewhere, the present study reveals that there continues to be a lag in translating these findings into improved organizational and clinical processes.

Strengths and limitations

The present study’s strength resides in the breadth of hospitals that were surveyed, with all 15 Canadian paediatric centres being represented. While our results enable us to draw conclusions about the state of mental health practices in these paediatric institutions we cannot, however, draw conclusions on care provided in general EDs where many children also receive emergency mental health care. Study limitations also include interviewing a single ED representative, and that the majority of those representatives were unaware of ED service evaluations. These responses suggest that study findings may not entirely reflect paediatric mental health evaluative processes that may or may not exist. Because study participants were identified as the most knowledgeable in their ED, but were not necessarily aware of the evaluative aspects of their ED’s protocols/guidelines/processes, we recognize an important opportunity for EDs to address this knowledge gap by developing and/or discussing evaluative efforts.

CONCLUSIONS

The present study demonstrated that there are a variety of mental health care practices in Canadian paediatric EDs, and that a vast majority of the practices used in child and youth mental health were not considered to be evidence based. Consideration of which mental health resources are necessary to optimize care is required to ensure evidence-based, effective services are provided to children and youth.

APPENDIX 1. Clinical practice survey

Scope and purpose 1. What is the overall purpose and scope of the [protocol/guideline]? 2. Is the [protocol/guideline] specifically described?

Stakeholder involvement 3. Which professional groups were involved in developing the [protocol/guideline]? Examples include physicians, nurses, crisis workers, administrative staff. 4. Has the [protocol/guideline] been informed by patients’ views and preferences? 5. Who uses the [protocol/guideline]? Examples include physicians, nurses, mental health staff (crisis workers, psychiatrists, social workers), administrative staff. 6. Has the [protocol/guideline] been pilot tested? (eg, initially evaluated)

Rigour of development 7. What is the [protocol/guideline] based on? Examples include hospital protocols, professional/clinical experience, national/international recommendations, research evidence. 8. Does the [protocol/guideline] outline health benefits, risk, side effects for patients and family? 9. Was the [protocol/guideline] externally reviewed by experts prior to implementation? 10. Is there a procedure for updating the [protocol/guideline]? Please describe the process (eg, administration receives regularly updated material [literature, research evidence, hospital policies] and makes changes as required).

Clarity and presentation 11. Are care processes in the [protocol/guideline] specific and unambiguous? 12. Are the different options for management clearly presented? 13. Are recommendations for management easily identifiable? 14. Are care processes in the [protocol/guideline] supported with tools for application? If yes, please identify the tools.

Applicability 15. Have the potential organizational barriers for care processes been accounted for [for this protocol/guideline]? If yes, please describe how. If no, please describe what barriers exist and why. 16. Have the potential cost implications of applying the [protocol/guideline] been considered? 17. Does the [protocol/guideline] include review (evaluation) criteria?

Overall assessment 18. Based on this discussion of the [protocol/guideline], what is your overall assessment of its scope and implementation?