Reducing length of stay and return visits for emergency department pediatric mental health presentations

Abstract

Background Variability in expertise and risk tolerance among emergency departments (ED) clinicians, when assessing and managing pediatric mental health presentations, leads to increased resource utilization. HEARTSMAP is a validated electronic tool that supports ED clinicians in psychosocial assessments and disposition decision making. Methods We used interrupted time series analysis (September 2016-December 2019) and multivariable regressions to measure the impact of integrating HEARTSMAP into ED practice on pediatric mental health presentations length of stay and return visits, at two pediatric EDs. The intervention site used HEARTSMAP trained ED clinicians to assess and manage mental health presentations, and reported bi-weekly ED median length of stay and 30 days-return visits for 15 months and a year, during passive and active implementation of HEARTSMAP, respectively. The control site used psychiatric nurses to assess and manage patients and was only exposed to passive implementation. Results HEARTSMAP average uptake was on average 47.4% (range 23.8-74.6%) during active implementation at the intervention site, while the control site showed no uptake throughout the study period. Incremental HEARSTMAP (each percent increase) use was associated with a reduction of 1.8 min (95% CI 0.8-2.9 in ED length of stay and 0.3% (95% CI 0.2-0.5 in 30-day return visit rate. This translates to an adjusted average reduction of 85.3 min in ED length of stay and 15.2% in 30-day return visits for youth with mental health presentations. Conclusion Use of HEARTSMAP in the ED can decrease length of stay and return visits for emergency pediatric mental health visits, in a fixed-resource setting.

Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review

“…For outcomes, ten studies reported on emergency admissions, six reported LOS in the emergency department, six on LOS in inpatient setting, and six on inpatient readmissions after discharge. Factors significantly associated with emergency admissions in multivariate analyses were (i) at the service level, higher volume of emergency visits (incident rate ratio, IRR = 1.004, 95% CI 1.003–1.005), and proportion of MHR emergencies (IRR = 1.004, 95% CI 1.002–1.006) [ 27 ]; (ii) at the individual level, older age (OR = 1.17, 95% CI 1.03–1.33), suicidal ideation with or without self-harm (OR = 3.07 or 4.70, 95% CI 1.12–11.01), and clinical diagnoses (when compared to depression), including bipolar or other mood disorders (OR = 13.05, 95% CI 3.57–47.71), and oppositional defiant disorder or conduct disorder (OR = 3.88, 95% CI 1.11–13.58) [ 30 ].…”

“…The first set of innovations improved psychiatric triage in the emergency department, including telepsychiatry consultations ( N = 2), multidisciplinary staffing ( N = 3), and clinical guidance training ( N = 1), which were effective in reducing LOS [ 27 , 34 , 37 , 39 ] and emergency admissions (see Table 1 ) [ 26 , 34 , 38 ]. Innovations for staff restructuring formed a multidisciplinary team comprising child psychiatrists and mental health social workers, supplemented with staff training in psychiatric triage, which reduced admissions 4–16% and LOS by 85–150 min ( P < 0.05).…”

“…Innovations for staff restructuring formed a multidisciplinary team comprising child psychiatrists and mental health social workers, supplemented with staff training in psychiatric triage, which reduced admissions 4–16% and LOS by 85–150 min ( P < 0.05). [ 27 , 34 ] Multidisciplinary staffing for medical and psychiatric assessments supported a new referral pathway to an urgent care team, which reduced admissions from the emergency department from 6.3 to 2.3% (F(3,42) = 4.6, P < 0.05) [ 38 ]. Next, the use of telepsychiatry consultations in the emergency department reduced emergency admissions (OR = 0.42, 95% CI = 0.30–0.59, P < 0.01); which was sustained after accounting for small differences in age and diagnoses between pre- and post-intervention cohorts (adjusted OR = 0.41, 95% CI 0.28–0.58, P < 0.01) [ 26 ].…”

“…and emergency admissions LOS reduced 14.7–12.1 h ( P < 0.001). Admissions decreased (17–1%, P < 0.001) Ishikawa [ 27 ] (Canada) Children and adolescents with acute psychiatric concern, aged 0–17 years Non-randomised control trial 2016–2019 Staff restructuring (staff training on mental health assessment and deployment at site) Total psych visits N = 6576 (intervention N = 3467, control N = 3109) Control site at another paediatric emergency dept. with RMNs LOS in emergency dept.…”

“…There was considerable variability between study methodologies, particularly the post-intervention time frame to capture the intervention effects. The main area of weakness was the comparability of intervention and control groups, whereby four studies provided no statistical calculation, only six controlled for potential confounders, and only three used a rigorous method such as propensity score matching or interrupted time series analysis [ 25 , 27 , 38 ]. All studies were included in the narrative synthesis.…”