Emergency Department Issues

In this issue, RAR is focused on recent research articles on the topic of child mental health and emergency department issues. I thank our four mental health and pediatric experts for their contributions in identifying important papers and highlighting key aspects of these works.

John D. McLennan

Dr. Matthew Morrissette recommends a paper by Wharff et al. (1) describing a clinical trial investigating the use of family-based crisis intervention (FBCI) for suicidal adolescents and their families presenting to the emergency department. FBCI is intended to bolster the abilities of patients and their families to effectively manage suicide risk in the home environment without the need for inpatient hospitalization. FBCI is a brief, single-session intervention involving a series of modules focused on areas including psychoeducation, cognitive-behavioral skill building, and safety planning. In this study, adolescents and their families were randomized to receive FBCI or treatment as usual. Outcome measures included the rates of inpatient hospitalization among the two treatment groups.

This study is important since it draws attention to the benefits of focussing interventions on the family unit rather than individuals alone. The findings of this study are especially salient at a time when psychiatric presentations to emergency departments among adolescents is on the rise, and finite inpatient resources are being stressed. Furthermore, inpatient psychiatric hospitalization is often considered to be a “last resort” for youth presenting in crisis, for reasons including the potential for increasing long-term suicide risk by negatively reinforcing maladaptive behaviors. Effective, timely intervention in the emergency department may obviate the need for inpatient hospitalization and may enhance the capacities of adolescents and their families to safely manage risk outside of hospital.

Matthew Morrissette, MD, FRCPC (Psychiatry)

Assistant Clinical Professor

Department of Psychiatry, Faculty of Medicine & Dentistry

University of Alberta

Edmonton Alberta

Dr. Renée Pang recommends an article from Esposito et al (2020) titled “Improving Mental Health Communication from the Pediatric Emergency Department to Primary Care” (1). This study demonstrates that improving communication and documentation tools in the Emergency Department (ED) dramatically enhances the ability of the primary care provider (PCP) to follow up on identified issues from universal mental health screening. This research adds to the emerging body of evidence suggesting that universal mental health screening is critical in generalized settings such as the ED. Of particular note, most ED patients who screened positive for mental health concerns such as suicidality or depression, did not present with a primary mental health issue (77%). Early identification of mental health concerns is critical, as early interventions and treatment for adolescent mental health disorders in the primary care setting can profoundly improve outcomes for these patients, increasing remission rates, and subsequently decreasing health resource utilization (2). Given this, improved communication between the ED and the PCP represents a critically important area of opportunity to improve the integration of post-crisis care for these patients. This focus on communication exemplifies a feasible intervention for ED physicians to consider and implement in their institutions. Furthermore, this innovative tool would easily adapt to a wide range of clinical settings to facilitate further optimization of treatment and management pathways, and thus clinical outcomes, for adolescent populations.

Renée Pang, MD, FRCPC (Pediatrics)

Adjunct Professor, Department of Psychiatry

Adjunct Professor, Department of Pediatrics, Schulich School of Medicine, Western University, London, Ontario.

Drs. Bruce Wright and Amanda Newton recommend…Have you ever wondered what a parent experiences as they wait with their child to be admitted or transferred for psychiatric care? Have you ever been frustrated with boarding times and concerned about ensuring and maintaining patient safety? If so, Drs. Bruce Wright and Amanda Newton recommend reading a study published in the Journal of Hospital Medicine by McCarty and colleagues (1).

In this qualitative study, McCarty and colleagues explored the experiences and perspectives of, emergency department (ED) and inpatient boarding at a tertiary care academic medical center in the Northeastern US. The center is representative of where most children in Canada receive care—in a non-pediatric hospital without in-house pediatric psychiatry beds. Nineteen clinicians—nurses and physicians from an ED, consultation liaison service and inpatient psychiatry—and 11 parents of admitted children were interviewed. Interview data were used to develop a framework that identifies the hospital infrastructure and processes needed for care delivery as well as outcomes that can be measured to evaluate care. The framework accounts for the impact of boarding on patients, caregivers, and clinicians.

Why is this study worth reading? McCarty and colleagues highlight the moral distress that was described by clinicians: “know[ing] the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” If you see yourself reflected in the findings of this study, the study’s framework may be the catalyst needed to plan for changes in how boarding is implemented where you practice.

Bruce Wright, MD, FRCPC (Pediatrics)

Associate Professor

Division of Pediatric Emergency Medicine, Department of Pediatrics

Faculty of Medicine & Dentistry, University of Alberta

Edmonton Alberta

Amanda Newton, RN, PhD

Professor

Division of General Pediatrics, Department of Pediatrics

Faculty of Medicine & Dentistry, University of Alberta

Edmonton Alberta

Dr. Mohamed Eltorki recommends reading an article by Willoughby et al (1). In this study, they surveyed a longitudinal cohort of 1073 children annually in their school for 3 years, aged 8–14 years. Their aim was to determine if age is associated with pattern of self-reported self-injury behaviors. In addition, they investigated the association between self-injury and adjustment difficulties as well as the parents’ awareness of child-self injury. The study was novel since it included younger children enrolled in Grade 3 to 5. It sheds some light on the frequency of self-harming behaviours in younger children and risk factors for self-harm. This may be important in screening for self-harm at an earlier age to target children at risk for early interventions, such as building coping skills for common adjustment difficulties encountered in this age group.

Mohamed Eltorki, MBChB, FRCPC (Pediatrics)

Assistant Professor

Department of Pediatrics

Faculty of Health Sciences, McMaster University

Hamilton, Ontario