Table 2.

Fact sheet for advocates:^aED use healthcare inequities among children and youth with mental health conditions

ED utilization rates

1. ED utilization by children and youth for mental health conditions has increased as much as 50% in the U.S. during a recent 5-year period (Kalb et al., 2019)

2. This is more than triple the rate of increase by children and youth for ED visits that are unrelated to mental health (Hoffmann et al., 2019b)

ED inequities

3. The increased ED utilization for mental health conditions is substantially higher among racial/ethnic minorities: 91% increase among Hispanic children and youth, 53% among African Americans, and 9% among non-Hispanic Whites (Kalb et al., 2019)

4. ED utilization in the U.S. is increasing among children and youth who have public insurance or are uninsured and declining among those with private insurance (Kalb et al., 2019)

ED referral

5. Increased ED utilization is driven largely by the referral of non-acute children and youth, with as many as 39% of referrals to EDs deemed inappropriate (Grudnikoff et al., 2015; Soto et al., 2009)

6. Of the nearly 50% of ED referrals of children and youth with mental health conditions that come from schools, most are not evaluated by a school nurse or professional prior to referral, and almost half of the referrals are likely to be deemed inappropriate (Grudnikoff et al., 2015)

7. The majority of children and youth with mental health conditions who visit an ED have an outpatient provider, but only 1 in 5 seek an outpatient evaluation prior to the ED visit and less than half of these actually receive the outpatient evaluation (Soto et al., 2009)

8. Inappropriate referrals of children and youth to an ED are a major concern because of the overstimulating nature of the ED environment, their exposure to other psychiatrically and medically ill individuals, and the frequent lack of adequate care in these settings, which can lead to increased agitation (Frosch et al., 2011; Sheridan et al., 2015)

ED quality of care

9. Parent and child expectations for an ED visit are frequently unmet, including a desire to feel better, receive guidance about what to do or how to cope, a diagnosis, treatment or a connection to treatment, or admission to a hospital (Cloutier et al., 2010)

10. Evidence-based treatments and best practices for serving children and youth with mental health conditions in EDs have been identified but are not available in the vast majority of EDs (American College of Emergency Physicians, 2019; Chun et al., 2013; Grover & Lee, 2013; Kalb et al., 2017)

11. Among children and youth with mental health conditions who visit an ED, it is estimated that only 16% are seen by a mental health professional and only 37% of those presenting with a suicidal attempt or self-injury are seen by a mental health professional (Kalb et al., 2019)

12. There is an absence of proven measures for assessing the quality of ED mental health care for children and youth (Hoffmann & Foster, 2020)

13. The clinical outcomes of an ED visit are seldom assessed or studied, and follow-up is infrequent; so, little is known about the effects of these visits (Cappelli et al., 2019; Patton & Borschmann, 2017)

ED length of stay

14. Children and youth with mental health related visits stay twice as long in EDs than those with visits unrelated to mental health, visit lengths are expanding ten times faster than for non-mental health visits, and 1 in 5 mental health related visits last longer than 24 h (Hoffmann et al., 2019a)

15. Up to 50% of children and youth admitted to psychiatric inpatient units experience boarding (waiting for an extended time) in EDs or medical inpatient units, sometimes for days (McEnany et al., 2020)

Reducing ED utilization

16. There are promising initiatives to reduce ED utilization through mobile and community crisis services, START programs, and learning communities focused on EDs and their community partners (Fendrich et al., 2019; Kalb et al., 2016)

^aSome data has been simplified for presentation in the Fact Sheet format. Additional data is available in the body of the article and the cited sources