Treating Mental Health Emergencies in Children

Nancy A. Melville


February 15, 2019

For pediatric patients in a mental health crisis, the typical busy emergency room setting can easily further exacerbate an already traumatized state. To keep these situations from escalating, mental health experts across the country are implementing innovative multifaceted programs that aim to better serve these patients while also improving staff confidence.

At Nemours Children's Hospital in Orlando, Florida, for instance, child psychiatry experts have developed an intervention called the REACH (Respecting Each Awesome Child Here) Program to better address the needs of some of the most challenging (and common) mental health emergencies: those involving patients with autism spectrum disorder (ASD).

Figure 1. Cara Harwell, ARNP. Courtesy of Nemours Children's Health System.

"A main issue is that a lot of emergency room staff are not trained in these types of cases and tend to go toward medication or restraining the patient as the first line, but that really should only be the last resort," nurse practitioner Cara Harwell, ARNP (Figure 1), who helped develop the program, told Medscape Medical News.

The REACH program is among the first models of its kind in the country to specifically address the unique needs of ASD children in the emergency department (ED), such as their hypersensitivity to environmental stimuli, including bright lights, loud sounds, pinging monitors, and a possibly chaotic atmosphere.

Key features of this program include a special sensory-friendly exam room (Figure 2) with accommodations including dim lights, soft music, and the use of projectors and star lights. Various types of distraction objects are also placed throughout the ED, including an interactive "bubble column" (Figure 3), toys, tactile stimulation discs installed on the wall, and an interactive light dome on the ceiling.

Figure 2. Sensory room. Courtesy of Cara Harwell, ARNP.

Figure 3. Bubble column. Courtesy of Cara Harwell, ARNP.

"Children can, for instance, change the speed and light in the bubble column, and that can be really intriguing to them," Harwell said. "They will often want to go in and actually interact with it, as opposed to just being asked to go in a room with a normal bed and machines, which can be frightening to them."

Policies directed towards the staff include avoiding having multiple people in the room at one time, unnecessary alarms, or other potentially disruptive stimuli. They are also trained to quickly recognize and manage anxiety and agitation in psychiatric patients.

Patient Benefits: Medications and Restraints Are Rarely Needed

In an effort to assess the REACH program's effectiveness, Harwell and colleagues evaluated data from 860 encounters with ASD patients after the program's implementation from 2016 to 2018.

Their findings, presented in December at the Institute for Healthcare Improvement's National Forum in Orlando, Florida,[1] showed notable improvements for patients and staff alike. Of 617 unique patients, only 49 received an anxiolytic and none required antipsychotic or alpha-agonist treatment.

"Additionally, physical restraint was extremely infrequent," the authors reported.

Although data on comparative rates of medication and use of restraints in ASD patients is lacking, one recent study showed that 13% of children with ASD had used at least one emergency service over just a 2-month period, and sedation or restraints were used as much as 23% of the time.[2]

The unnecessary use of medication is of particular concern. Although medication may seem to be a logical choice when a patient in the ED is highly agitated, with ASD, the effects may only make things worse.

"The intention may be to bring about sedation, but sometimes these ASD children may have the opposite effect with medication," Harwell said. "It can actually make them even more hyperactive, or, depending on how the medicine is given -- sometimes injected or sprayed in the nose -- [it] can trigger patients to become more afraid or aggressive because they don't understand what's happening."

She added, "We have learned that being able to prevent escalation has been so much more effective than giving the medicine and holding patients down unnecessarily."

Staff Benefits: Increased Comfort and Confidence

As part of the REACH program, staff members participate in mandatory training at least every 2 years and throughout the year. Training shows important benefits in boosting staff confidence in treating patients with ASD. According to a staff survey,[1] 15% of providers reported an increase in comfort working with agitated patients after implementation of the program, 39% an increase in knowledge of ASD signs and symptoms, and 58% an increase in autism awareness.

"Overall, the study supports that REACH Program training is effective at improving provider comfort and knowledge when treating children with ASD," Harwell said.

Although the REACH program was established with ASD patients in mind, Harwell noted that the benefits extend to ED patients with other psychiatric conditions.

"I wanted to make sure this wasn't just for autism patients, because there is so much overlap between ASD and other behavioral and mental health conditions that also don't handle the emergency room well. So we kept it broad, and our goal was to provide special accommodations to any child that needed these interventions."

Bellevue Hospital Program Focus Is on Comprehensive Care

Measurable improvements have also been noted in a program at New York City's Bellevue Hospital Center, which also focused on taking extra steps to stabilize pediatric patients and provide a full range of mental health services.

The Children's Comprehensive Psychiatric Emergency Program, described as one of the only such environments in the country dedicated solely to the care of children and adolescents, was implemented in 2015 with a focus on 3 main components: an emergency evaluation area, pediatric extended observation unit, and outpatient acute care services.

In addition to providing extended observation beds to allow for brief stabilization, the center is staffed around the clock, 7 days a week, with child psychiatrists and child psychiatric nurses, social workers, psychologists, and caseworkers.

Figure 4. Ruth Gerson, MD.

All patients receive an immediate, thorough psychiatric and psychosocial evaluation by child mental health specialists, regardless of their socioeconomic status, said child and adolescent psychiatrist Ruth Gerson, MD (Figure 4), director of the Children's Comprehensive Psychiatric Emergency Program and co-author of the book Helping Kids in Crisis: Managing Psychiatric Emergencies in Children and Adolescents.

"Nationally, if a child goes to an emergency room after a suicide attempt, they have a less than 50% chance of getting any kind of mental health assessment," Gerson said. "Here, every child who comes through our doors, day or night, regardless of their insurance status, gets a comprehensive assessment by a child psychiatrist, and many are also seen by a child psychiatric social worker or psychologist."

The program includes 6 rooms, some single and some double, with closets and televisions in each, where patients can have more privacy than a typical ED and staff are taught to put patients at ease.

"Everyone here is trained to help youths who are experiencing emergencies to feel comfortable and safe, to know that they are not being judged, and to understand why they are hurting and what they need."

Having Appropriate Staff to Treat At-Risk Youth

A recent study[3] assessing the Children's Comprehensive Psychiatric Emergency Program showed that although the vast majority of patients presented in crises, nearly two-thirds (59%) could be discharged after evaluation and were given access to immediate outpatient follow-up. An additional 13% of patients could be stabilized in less than 72 hours.

"This suggests that brief stabilization with active treatment is an effective alternative to inpatient admission for a subset of patients, and should be used more broadly for both quality improvement and cost containment," Gerson and colleagues wrote.

Given the presence of child psychiatrists in the ED, the authors added that the intervention also likely improved rates of admission among those who appropriately required additional inpatient care, such as those at risk for suicide, than is possible in hospitals without this available staff on site.

Research[4,5] has shown that the likelihood of hospitalization for suicidal behavior depends largely on whether a child presents to a children's hospital or to an ED staffed by pediatricians or psychiatrically trained professionals, rather than to a general medical ED without pediatrics or psychiatry available. Gerson and colleagues noted that that this is troubling, given that approximately three-quarters of EDs do not have pediatricians or pediatric emergency medicine physicians.[6] Further compounding the problems is the fact that rates of inpatient visits for suicidal ideation and self-harm among children and adolescents are significantly on the rise,[7] and that the chances of completed suicide are known to increase after attempts.[8,9,10]

A Nurse-Led Intervention for Overcoming Staffing Limitations

At Seattle Children's Hospital, an intervention launched in 2011 sought to overcome those staffing issues by providing for a nurse-led response team focusing on also providing mental health services 24/7 for psychiatric cases.

Before the intervention, mental health pediatric patients were managed by a variety of providers, ranging from social workers to medical residents under the supervision of an ED attending physicians, and although psychiatry fellows were available for consultation in difficult cases, their involvement was infrequent. The evaluation process was time-consuming for patients and families alike.

Under the intervention, the round-the-clock mental health team included a mental health evaluator, who was either a nurse with at least 2 years of psychiatric nursing experience or a social worker with a master's degree, and a pediatric mental health specialist: a bachelor's degree-level provider who provided patients and families with home disposition planning and crisis management training, as well as monitored patient behavior during their time in the ED.

According to a 2016 study of the intervention,[11] the program showed significant improvements in the mean ED length of stay (332 vs 244 minutes) and in the need for security physical interventions (2.0% vs 0.4%) and restraint use (1.7% vs 0.1%) compared with the previous year.

Surging Patient Visits Present a Continual Challenge

Changes that have occurred since the study's publication just 3 years ago, however, underscore the ongoing challenges that EDs face in the current climate of mental illness.

"From 2015 to 2018, we saw a more than 50% increase in the number of patients with mental health complaints, far outpacing the increases we've seen in patients with medical complaints," Neil Uspal, MD, an attending physician in pediatric emergency medicine at Seattle Children's Hospital, Washington, and co-author of the study, told Medscape Medical News.

The increase, consistent with reports of soaring patient volumes nationwide,[12] took their toll, and as the center struggled to keep up with shortages of beds for psychiatric patients, their length of stay times and use of restraints have since increased.

"We've had significant challenges at periods of high volume with not being able to identify beds in the community for patients that need inpatient admission," said Uspal, who is also an associate professor at the University of Washington.

"This forces us to board patients, taking rooms offline and backing up the entire system," he said.

In the meantime, the program has had to evolve and grow.

"We have needed to greatly expand the scope of our program, such that we can have up to 4 mental health evaluators working simultaneously. Our busiest hours are often at night, so that is where we have focused much of our staffing," he explained.

"The key is we have social workers and nurses who are full time in the ED dedicated to treating this population. This allows them to really understand psychiatric evaluation, resources, and navigating the system vs general social workers, who are asked to do it all."

Despite the challenges and growing pains, the dedicated 24/7 mental health team model has been essential in preventing the increases in length of stay from being far greater.

"Not only [has it prevented those increases, but] the intervention results in higher-quality care, including arranging appropriate follow-up, de-escalation of patients, etc," Uspal said.

'The Key Is Having a Process'

Programs implemented at Clemson University[13] and at Oregon Science and Health University[14] have also been reported to spur improvements in child and adolescent psychiatric emergency cases. However, the costs of such expansions may be an obstacle in many settings.

In addition, researchers at Hassenfeld Children's Hospital at NYU Langone Health in New York City and other centers describe important improvements with an ASD Care Pathway program,[15] described as "a scalable approach to improving care in general psychiatric units through staff training and a package of autism-specific intervention strategies."

Gerson, meanwhile, noted that the program at Bellevue Hospital Center provides some training in the management of pediatric psychiatric patients for colleagues at other ED centers.

Uspal notes that the Seattle Children's Hospital ED mental health intervention was established as the result of a quality improvement process using Lean methodology,[16] which was developed in industry to eliminate wasteful process steps and has since been adapted in healthcare.

He underscores that each center needs to similarly tailor its own approach: "Every facility is going have different challenges specific to that institution. The key is having a process where those needs can be identified and addressed."


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