乌鸦传媒

For children with behavioral conditions, psychiatric co-management in the observation unit of a pediatric emergency department was associated with shorter stays and fewer inpatient admissions, an observational study showed.

At one urban academic center, the psychiatric co-management model led to a length of stay of 3.5 hours in the unit versus 10.1 hours in another with just social work available (P<0.001), according to researchers led by Rachel G. Kasdin, MS, of the Icahn School of Medicine at Mount Sinai in New York City.

Inpatient admission was 1.9-fold (95% CI 1.6-2.3) less likely with the extra psychiatry resources available to the pediatric observation unit.

The findings were published in and presented as a poster at the Pediatric Academic Societies meeting in Toronto.

"These findings are consistent with outcomes of an adult psychiatric observation unit and suggest value to patients in racial, ethnic, and sexual minority groups who disproportionately use the PED [pediatric emergency department] for healthcare," the researchers noted.

Psychiatric co-management "may decrease the burden of care in the PED and reduce demand for inpatient resources for children with psychiatric emergencies," they added, noting the "unprecedented demands" for pediatric mental healthcare given the fragmented infrastructure for it, shortages in both in- and outpatient psychiatric services, and barriers to preventive care.

Pediatric observation units are supposed to evaluate and treat well-defined conditions for brief periods, but they've been eyed for behavioral care as well given the success of psychiatric observation units available for adults.

One of a psychiatric observation unit in emergency departments at Yale New Haven Hospital in Connecticut showed a reduction in emergency department boarding for patients requiring acute psychiatric evaluation from an average 155 minutes down to just 35, with similar reductions in crisis intervention unit length of stay and total length of stay and a lower overall psychiatric admission rate compared with before the observation unit's availability.

"A handful of leading children's hospitals currently have an emergency behavioral health observation unit for children, but this is more of a new and emerging model," said Jennifer Hoffmann, MD, of Lurie Children's Hospital of Chicago, which started a similar program to the one described in the study about 6 months ago.

She described promising results as well, as "about two-thirds of the patients that we are placing in observation status are able to be discharged home instead of admitted to an inpatient psychiatric unit."

However, that's only feasible for centers that have child and adolescent psychiatrists on staff, not those where most children get their emergency care -- at non-children's hospitals, such as community hospitals or general emergency departments -- which "very rarely have child psychiatrists on staff," Hoffmann noted.

A challenge is the significant workforce shortages of child and adolescent psychiatrists across the country, with many counties having none at all, she added.

Kasdin's group compared data from Jan. 1 to Dec. 31, 2022, at two pediatric emergency departments with similar patient populations and child psychiatry consultation services. One had a separate pediatric observation unit with dedicated staff for psychiatric reassessments, medication adjustment, social work, and child-life services. The other had only social work available.

During the study period, health records for all those age 18 and younger with an initial decision of inpatient admission for a primary behavioral condition were analyzed.

That admission decision was made by emergency department and psychiatry professionals using standardized risk assessments, but it could be reversed by the observation unit co-managing team or the emergency clinician at the site without the psychiatric co-managed observation unit.

The two sites' patient populations had similar average age (mean 14.6 years), sex (54.7% female, 8.8% nonbinary), and racial makeup (77.0% nonwhite). Payor type and chief complaint were also consistent between the two centers.

Reversal of the decision to admit was common in the psychiatric co-management model unit, with 42 of 88 (48%) sent home; whereas none of the 82 treated in the other center had their admission decision reversed.

Because each decision reversal prevented an average of 12.0 days in the hospital, the psychiatric co-management model saved a potential 504 inpatient-days, the researchers noted.

Total treatment time and inpatient length of stay was similar between the two sites.

"Given the fragmented pediatric mental health infrastructure, limitations include knowledge gaps in outpatient follow-up, family resources, housing status, and other social determinants of health," the researchers noted.

Another key limitation was lack of description of the types of brief interventions that the child psychiatrists provided in order to achieve these results, Hoffmann cautioned.

"There have been some studies of brief interventions provided in emergency department settings that have improved connection to follow-up care and have decreased subsequent suicide attempts," she told 乌鸦传媒. "Further work is needed to determine what's the secret sauce of interventions that can be provided in these emergency settings in order to enable children to continue to be safe receiving care in the community instead of in hospital settings."

If that could be determined, it's also possible that similar interventions could be administered by psychiatric telehealth or even by emergency physicians, she suggested. "That could expand the reach of the expertise of child psychiatrists to surrounding EDs that don't have a child psychiatrist on staff," she said, noting also that "there are brief interventions that emergency clinicians can provide, such as universal suicide screening, safety planning, and lethal means restriction counseling."

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