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America's emergency rooms are being flooded by children suffering from psychiatric emergencies like anxiety, depression and suicidal thoughts or attempts, a new joint report from three leading medical associations warns.
This surge in pediatric mental health emergencies has overwhelmed ERs in the United States, says the joint paper from the American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP) and Emergency Nurses Association (ENA).
Unfortunately, the kids coming to the ER are less likely to receive the ongoing mental health care they truly need, said lead author Dr. Mohsen Saidinejad, director of pediatric emergency medicine at the Ronald Reagan UCLA Medical Center.
“The ER has become a de facto referral center for all of these problems, and there's too many of them for the emergency department to manage,” said Saidinejad, a member of the AAP and ACEP committees on pediatric emergency medicine. “That is not who we are as ER physicians. We are not mental health professionals. We cannot provide definitive care.
“We can screen, we can identify those at harm risk, but that's about it, so the ER is really not the most appropriate place to manage these cases," Saidinejad said. "And I think we are becoming that because there isn't any other place for these kids to be sent."
The joint policy statement and technical report were published Aug. 16 in the journal Pediatrics.
Every year, about half a million children with mental and behavioral health problems are evaluated in ERs, the joint report says.
ER visits spurred by mental health problems increased by 120% at children's hospitals between 2007 and 2016, the report said. The rate among general hospitals rose by 55% during the same period.
The stress and strain of the pandemic has further intensified this crisis, said Dr. Madeline Joseph, a pediatric emergency physician at University of Florida Health in Jacksonville.
In 2021, U.S. Surgeon General Dr. Vivek Murthy released an advisory that warned of the growing mental health crisis among children, declaring it a national emergency.
Longer hospital stays
“We have witnessed firsthand the dramatic increases in Emergency Department visits for all mental health emergencies, including suspected suicide attempts,” said Joseph, an ACEP spokeswoman.
ER cases involving a pediatric mental health crisis tend to be very complex and require a much longer hospital stay – 17 hours versus 5 hours, on average, for all ER visits, the report says.
That includes an 8-hour stay versus a 4.5-hour stay for patients who are discharged, and a 27-hour stay versus a nearly 18-hour stay for those who are admitted to the hospital, the report says.
“Unfortunately, it is not unusual for patients with mental and behavioral emergencies to stay in the ED for over 48 hours, which can exacerbate their emergencies,” Joseph said.
These complex cases also drain “resources that would have been needed to run the normal medical operations of the ER, so that increases of length of stay for the other patients as well,” Saidinejad added.
Another concern is that ER teams are designed to work at a fever pitch, moving from case to case as quickly as possible.
Children in psychiatric crisis need follow-up care, and they are less likely to get that follow-up if they go to an ER, Saidinejad said.
“I would say about 80% of all children who come with mental and behavioral health concerns to the ER can be safely discharged from the ER and do not require psychiatric hospitalization, but what they do require is a close outpatient follow-up,” Saidinejad said. “They need somebody to keep an eye on them, and an ER is really not the ideal place. We cannot ever follow up with a patient after discharging home."
America's health care system currently operates on the “medical home" model, with a person's primary care doctor tracking all their care and making sure they get required follow-up treatment, Saidinejad said.
“A child who gets seen in the ED is disconnected from their normal continuum of care, and being able to take that child who came to the ED and connect them back to their primary home and connect them to mental health resources is another challenge,” Saidinejad said.
Where to go instead of the ER
The report recommends specific ways to improve mental health treatment in an emergency department, including dedicated spaces for psychiatric screening, selection of good screening tools, and one-on-one treatment and monitoring for at-risk patients.
But it would be best if many of these children never reach an ER, but are instead referred to a psychiatric crisis center or community mental health center, Saidinejad said.
Primary care doctors, paramedics and other emergency workers should have access to lists of psychiatric providers in each community, and refer to those lists in determining where to take a patient in crisis, Saidinejad said.
"If there was awareness of these resources, people could perhaps skip the ER and directly refer to those services," he said.
However, Saidinejad allowed that this isn't an option for many communities, due to a lack of mental health resources.
"For every 124,000 children, there is one mental health professional, which is completely inadequate," Saidinejad said. “As many as 55% of all of the counties in the United States do not have one psychiatric professional."
Given that, beefing up America's mental health care system will be another necessary step in addressing this issue, Joseph said.
"Having adequate pediatric mental and behavioral health resources in both inpatient and outpatient settings is critical to relieve some of the pressure off EDs," Joseph said.
These could include mental health mobile crisis teams, as well as more mental health professionals in communities, Joseph said.
Telehealth also could help fill some of the gaps, with mental health workers online and ready to consult with primary care physicians in treating children in crisis, Saidinejad and Joseph said.
"There must be an availability of options and resources that people are aware of, so they don't say everybody needs to go to the ER," Saidinejad said. "We in the ER are basically a safety net. We can't say no to anything. We have to accept whatever comes our way. And I think that is why everybody is referring these children to the ER."
SOURCES: Mohsen Saidinejad, MD, director, pediatric emergency medicine, Ronald Reagan UCLA Medical Center, Los Angeles; Madeline Joseph, MD, pediatric emergency physician, University of Florida Health, Jacksonville; Pediatrics, Aug. 16, 2023
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