We aimed to describe the characteristics and disposition of youth referred from schools to the emergency department (ED) for psychiatric evaluations. Consecutive 12-month records of ED psychiatric consultations at a large urban hospital from 07.01.2009 to 06.30.2010 were retrospectively analyzed. School-initiated referrals were deemed inappropriate if youth were discharged from the ED without any recommended mental health follow-up. Of the 551 psychiatric ED evaluations, 243 (44.1%) were initiated by schools. Of all school referrals, only 19 (7.8%) children were psychiatrically hospitalized, 108 (44.4%) were discharged from the ED with a follow-up appointment; and 116 (47.7%) were discharged without arranged follow-up. Those with a chief complaint of "suicidality" (n = 109, 44.9%) were more likely to be discharged without arranged follow-up than youth with other presenting complaints (56.0 vs. 41.0%, p = 0.021). Altogether, only 37 (18.5%) of 200 school-referred youth with information were evaluated by a school nurse, social worker, or other professional before being sent to the ED. Students without in-school screening were significantly more frequently discharged without follow-up than students with in-school evaluations prior to the ED referral (51.5 vs. 27.0%, p = 0.0070; odds ratio = 2.87 (95% CI 1.30-6.31). Multivariate predictors of inappropriate school referrals of youth discharged without any outpatient follow-up were higher Children's Global Assessment Scale score (p < 0.0001), absent in-school evaluation (p = 0.0069), absent prior psychiatric history (p = 0.011) and absent current psychotropic medication treatment (p = 0.012) (r(2) = 0.264%, p < 0.0001). Altogether 44.1% of ED consultations were school referred, of which 47.7% were potentially inappropriate for the emergency setting. In-school screening, which occurred infrequently, reduced unnecessary evaluations by 52%.

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