Mental Health ED Referrals in Kids Often Unnecessary

Deborah Brauser

October 09, 2014

Many child psychiatric referrals by schools to emergency departments (EDs) are unnecessary, inappropriate, and a waste of resources, new research suggests.

Dr Eugene Grudnikoff

A retrospective examination of 243 psychiatric ED evaluations initiated by schools showed that only 8% of the students were hospitalized ― and 48% were discharged without need of any specific follow-up.

"This is a costly and misinformed practice across the US," lead author Eugene Grudnikoff, MD, staff psychiatrist at South Oaks Hospital in Amityville, New York, told Medscape Medical News.

In addition, only 19% of the youth referred by schools had been evaluated beforehand by a school health professional. However, these types of screenings reduced unnecessary evaluations by 52%.

"As our study shows, an in-school screening could simply solve most of this problem. But schools have no incentive to do such a screening. They are driven by their fear for liability," said Dr Grudnikoff in a release.

"I'm not saying don't send children you are concerned about to EDs. We're just suggesting having an extra screening before sending them out."

The study was published online September 27 in European Child and Adolescent Psychiatry.


Dr Grudnikoff recalled that during his fellowship training, he saw many young people sent to EDs for psychiatric evaluations unnecessarily.

"I realized pretty quickly that many of these kids who were referred for what was believed to be an emergency did not actually have an one. One of the major factors that create the situation is schools reacting to an incident and making on-the-spot decisions that require psychiatric clearance," he said.

"This includes removing the disruptive child and covering themselves as far as liability in case something does happen down the road."

The investigators evaluated health records from July 2009 through June 2010 for 551 psychiatric ED evaluations done at the University Hospital for the University of Medicine and Dentistry of New Jersey for patients younger than 18 years.

Most of the school referrals came from the Newark Public School District, where 51% of the students are black, 40% are Hispanic, and 8% are white.

Results showed that of the 551 ED evaluations assessed, 243 (44.1%) were from referrals by schools. The mean age of the students was 11.3 years, and 60.9% were boys.

Of the total school referrals, 19 (7.8%) children were hospitalized, 108 (44.4%) were discharged from the ED with psychiatric referral, and the remaining 116 (47.7%) were discharged without follow-up. Mean Children's Global Assessment Scale (CGAS) scores for the three groups were 35, 57, and 62.6, respectively.

The students who were discharged without follow-up "likely did not have the level of severity or urgency appropriate for emergency room level of care," note the investigators in the release, adding that these were categorized as "inappropriate referrals."

Only 18.5% of the referred students were previously evaluated by a school nurse, social worker, or counselor. There were fewer inappropriate referrals among these students than among those who were not first screened at school (27% vs 51.5%, P = .007; odds ratio, 2.87).

Significant predictors of inappropriate referrals included higher scores on the CGAS (P < .0001), not having an in-school evaluation (P = .007), not having a prior psychiatric difficulty (P = .01), and not currently taking psychotropic medications (P = .01).

Wasting Resources

The most common presenting complaint was suspected or actual suicidality (44.9%), followed by disruptive behaviors (21%) and homicidal/aggressive threats and behaviors (20.6%).

Interestingly, those with a chief complaint of suicidality were significantly more likely to be discharged without follow-up than students with other complaints (56% vs 41%, P = .02).

Events leading to ED referral included rough play on the playground, being caught with cannabis, submitting a poem with suicidal content, and sharing traumatic experiences with a counselor.

Dr Grudnikoff reported that one student was referred for ED evaluation because he said, "I'm so hungry for a burger, I could die" while standing in the lunch line.

"This type of thing does not constitute a psychiatric emergency. But some schools have a zero-tolerance policy and are afraid to be sued if anything happens," he said. "There were many incidences of a disruptive or nonserious situation that was blown out of proportion."

In addition, "the ED is not an optimal setting for addressing non-urgent mental health concerns, and its use in such a capacity contribute to non-continuity of treatment of chronic illness, poor adherence with follow-up recommendations, and relapse of symptoms," add the investigators.

Dr Grudnikoff said that inappropriately referring children and adolescents also wastes limited resources.

"Schools need to have discipline in a classroom for teachers to do their work effectively. But our findings reflect schools' inability to adequately manage disruptive behavior," he said.

"Overall, this itself is a disruptive practice to the student, the school, parents, and the healthcare system. And in terms of healthcare costs, it's really wasteful."

Dr Grudnikoff reports no relevant financial relationships. A full list of potential conflicts of interest for the other two study authors, including Dr Christoph Correll, are in the original article.

Eur Child Adolesc Psychiatry. Published online September 27, 2014. Abstract


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