The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Comparison of Outcome Tools Used to Test Mass-Casualty Algorithms in the Pediatric Population.

INTRODUCTION: Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose. STUDY OBJECTIVE: This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients. METHODS: An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools. RESULTS: A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The "modified Baxt positive and alive" outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. "Modified Baxt negative and <24 hours LOS" had the highest agreement with the COT green at 89%. CONCLUSIONS: Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.

Prevalence of marijuana use among trauma patients before and after legalization of medical marijuana: The Arizona experience.

BACKGROUND: In recent years, marijuana has become legal for use in many states, for either medicinal or recreational purposes. Objective: The primary objective is to determine if legalization of medical marijuana is associated with an increased use among trauma patients. Methods: Prospective observational study included three periods; (pre-legalization; period 1); legal to grow for medicinal purposes but no dispensaries open (period 2); and legal to purchase medicinal marijuana in a dispensary (period 3). The study included all adult trauma patients presenting to an urban level I trauma center in Phoenix, AZ. The prevalence of use (as defined by positive urine drug screen or self-reporting) in each time period was determined and compared using two sample tests of proportion. Confidence intervals for prevalence (self-reporting only) were compared with published age matched data from the same geographical region of the general population. Results: The prevalence of marijuana use increased significantly from pre-legalization (period 1) to post legalization (periods 2 and 3), but there was no significant change between the two post legalization periods. After controlling for age and sex, the odds of being marijuana positive post-legalization vs. pre-legalization was 1.36, p = 0.006 95%CI [1.09-1.7]. Overall, the prevalence of marijuana among trauma patients was nearly four-fold higher than the population as a whole in the same geographic region. Patients who use marijuana are more likely to use cocaine or amphetamine (OR 2.31; 95% CI 1.86-2.89) or had an ethanol level above 80 mg/dL (OR 1.57; 95% CI 1.32-1.87). Conclusion: The legalization of medicinal marijuana is associated with significantly increased prevalence among trauma patients. It appears that legalization, rather than the convenience of dispensaries, is associated with an increase in use.

Marijuana self-report compared with testing in trauma patients before and after legalization.

Background: Both marijuana use and legalization are increasing, and the cognitive effects of marijuana may play a role in trauma. Our objective was to assess the proportion of patients with a urine drug screen who self-reported use in a population of trauma patients.Methods: Self-report of marijuana use in trauma patients was recorded for patients with a positive urine toxicology screen at a Level 1 trauma center in Arizona prior to (1/2011 to 4/13/2011) and following (4/14/2011 to 9/2014) legalization of marijuana for medical indications.Results: Among patients with a positive toxicology screen who were able to report to utilization, 52.5% patients with a positive UDS for marijuana overall reported use. In the pre-legalization group, 59.3% reported use, while in the post-legalization group, 51.4% reported use (p = .188).Conclusion: Only about half of trauma patients with a positive urine drug screen for marijuana reported use. Self-reporting among UDS-positive patients demonstrated no significant change with the legalization of marijuana for medical reasons.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace.

INTRODUCTION: Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting. METHODS: We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant's (patient's) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center. RESULTS: We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different. CONCLUSION: Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

Involuntary Psychiatric Holds in Preadolescent Children.

INTRODUCTION: Little is known about the use of involuntary psychiatric holds in preadolescent children. The primary objective was to characterize patients under the age of 10 years on involuntary psychiatric holds. METHODS: This was a two-year retrospective study from April 2013 - April 2015 in one urban pediatric emergency department (ED). Subjects were all children under the age of 10 years who were on an involuntary psychiatric hold at any point during their ED visit. We collected demographic data including age, gender, ethnicity and details about living situation, child protective services involvement and prior mental health treatment, as well as ED disposition. RESULTS: There were 308 visits by 265 patients in a two-year period. Ninety percent of involuntary psychiatric holds were initiated in the prehospital setting. The following were common characteristics: male (75%), in custody of child protective services (23%), child protective services involvement (42%), and a prior psychiatric hospitalization (32%). Fifty-six percent of visits resulted in discharge from the ED, 42% in transfer to a psychiatric hospital and 1% in admission to the pediatric medical ward. Median length of stay was 4.7 hours for discharged patients and 11.7 hours for patients transferred to psychiatric hospitals. CONCLUSION: To our knowledge, this study presents the first characterization of preadolescent children on involuntary psychiatric holds. Ideally, mental health screening and services could be initiated in children with similar high-risk characteristics before escalation results in placement of an involuntary psychiatric hold. Furthermore, given that many patients were discharged from the ED, the current pattern of utilization of involuntary psychiatric holds in young children should be reconsidered.

Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool.

BACKGROUND: Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as over-triage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality. At this time, there is no validation tool specifically developed for the pediatric population to test an MCI algorithm's inherent capabilities to correctly triage children. OBJECTIVE: To develop a set of criteria for outcomes and interventions to be used as a validation tool for testing an MCI algorithm's ability to correctly triage patients from a cohort of pediatric trauma patients. METHODS: Expert opinion and literature review was used to formulate an initial Criteria Outcomes Tool (COT) that retrospectively categorizes pediatric (≤14 years of age) MCI victims based on resource utilization and clinical outcomes using the classic Red to Black MCI triage designations: Red - cardiopulmonary or mental status compromise needing intervention, Yellow - stable cardiopulmonary status but may require life or limb therapy, Green - minimally injured, and Black - deceased or likely to die given the circumstances. Using an anatomic approach, a list of criteria were defined and a modified-Delphi approach was used to create a summative COT that was reviewed by the American Academy of Pediatrics Disaster Preparedness Advisory Council. The resulting COT was independently applied to a weighted retrospective cohort of 25 pediatric victims from a single Level I trauma center by two reviewers to determine reproducibility. RESULTS: We created a Criteria Outcomes Tool (COT) with 47 outcomes and interventions to validate an MCI algorithm's triage designation. When the COT was applied to a cohort of 25 weighted pediatric charts, we identified the following resource utilization and outcome based triage designations: six Red, six Yellow, six Green, and seven Black triage outcomes. The 100% agreement was obtained between the two reviewers in each of the four categories. CONCLUSIONS: We designed an outcomes and resource utilization tool, the COT, to evaluate the ability of an MCI algorithm to correctly triage pediatric patients. Our tool has good reproducibility on initial study. KEY WORDS: pediatric; disaster; validation tools; triage algorithms; emergency.

Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance.

STUDY OBJECTIVE: We assess whether screening laboratory tests obtained to medically clear pediatric psychiatric patients altered management or disposition. METHODS: This was a retrospective chart review of consecutive patients younger than 18 years and presenting to an academic pediatric emergency department for medical clearance of an acute psychiatric emergency potentially requiring an involuntary hold (danger to self, danger to others, grave disability) from July 2009 to December 2010. Patients were identified by discharge diagnosis codes. History and physical examination and screening laboratory tests were reviewed for changes in management or disposition. Further analysis compared length of stay according to type of laboratory test performed. To avoid missing patients presenting with or for evaluation of an involuntary hold for whom an organic cause was diagnosed, charts with psychiatric chief complaints were reviewed for the same period. RESULTS: One thousand eighty-two visits resulting in 13,725 individual laboratory tests were analyzed. Of 871 visits with laboratory tests performed, abnormal laboratory tests were associated with 7 disposition changes (0.8%) and 50 management changes (5.7%) not associated with a disposition change. Twenty-five patients with noncontributory history and physical examination results had management changes, all non-urgent. One patient with a noncontributory history and physical examination result had a disposition-changing laboratory result, a positive urine pregnancy test. Patients who had any screening test performed had a longer length of stay than patients without testing (117 minutes longer; 95% confidence interval 109.7 to 124.4 minutes). In charts reviewed according to chief complaint, no patient was found to have an organic cause of their symptoms according to only screening tests. CONCLUSION: Screening laboratory tests resulted in few management and disposition changes in patients with noncontributory history and physical examination results but were associated with increased length of stay.

Prior treatment of fracture patients in a tertiary pediatric emergency department: informal referrals from other emergency departments.

BACKGROUND: The purposes of this study were to determine the following: (1) the percentage of fracture patients at a tertiary pediatric emergency department (ED) who previously sought treatment for the injury elsewhere and (2) how often such patients were sent from another ED. METHODS: A prospective survey was conducted in the ED of a tertiary pediatric medical center in a large metropolitan area. Patients who presented with suspected extremity fractures and previously sought treatment elsewhere were asked where they had sought treatment and whether staff at another ED had told them to come to the tertiary ED. Demographic, clinical, insurance, and transfer information were also collected. RESULTS: Ninety-two patients who had sought previous care for the injury elsewhere participated in the survey, with 82 (89%) ultimately being diagnosed with fractures. This represents 33% (82/246) of the patients with extremity fractures treated by the participating ED physicians during the study. Seventy-nine percent (73/92) of the subjects had previously sought treatment at another ED. For those who did not also visit a regular physician, 69% (37/54) were told to come to the tertiary ED by staff at the initial ED. No differences were observed based on race or insurance status because the study subjects were predominantly minority (91%, including 80% Hispanic) and lacking private insurance (84%). CONCLUSIONS: Seeking follow-up care in a tertiary ED, often on the advice of staff from another ED, is a common practice for this largely minority and poorly insured population. Because patients did not present to our ED until an average of 3 days after injury and many had been discharged to a primary care physician, it is likely that many of the patients did not require emergency care. This practice inefficiently uses limited emergency care resources. LEVEL OF EVIDENCE: Level II prospective survey.

Design and evaluation of a disaster preparedness logistics tool.

OBJECTIVE: The purpose of this article is to describe the development and testing of the Pediatric Emergency Decision Support System (PEDSS), a dynamic tool for pediatric victim disaster planning. DESIGN: This is a descriptive article outlining an innovative automated approach to pediatric decision support and disaster planning. SETTINGS: Disaster Resource Centers and umbrella hospitals in Los Angeles County. PATIENTS: The authors use a model set of hypothetical patients for our pediatric disaster planning approach. RESULTS: The authors developed the PEDSS software to accomplish two goals: (a) core that supports user interaction and data management requirements (e.g., accessing demographic information about a healthcare facility's catchment area) and (b) set of modules each addressing a critical disaster preparation issue. CONCLUSIONS: The authors believe the PEDSS tool will help hospital disaster response personnel produce and maintain disaster response plans that apply best practice pediatric recommendations to their particular local conditions and requirements.

The utility of safety counseling in a pediatric emergency department.

OBJECTIVE: Pediatric injuries have a significant impact on the medical system, costing lives and disabling many survivors. Although injury-prevention measures do exist, they are underutilized. A majority of families do not consistently receive counseling by a primary care provider (PCP). We attempted to demonstrate the efficacy of counseling families who presented to a pediatric emergency department with unrelated medical complaints. METHODS: A self-report questionnaire was administered to assess the home safety of patients 2 weeks to 12 years old presenting to the emergency department. Targeted counseling on areas noted to be unsafe was provided, and a 2-week follow-up telephone call was made to assess the effectiveness of the counseling. Information on previous counseling by a PCP was also collected and analyzed. Logistic regression was performed to determine significance and calculate odds ratios. RESULTS: Thirty-seven percent of caregivers recalled receiving any counseling at a PCP visit. Caregivers who had received prior counseling by a PCP were significantly more likely to have a safe home environment. Patients who were English speaking were significantly more likely to have received safety counseling than their Spanish-speaking counterparts. One hundred fifty families received counseling in the emergency department, and 117 were eligible for follow-up. Of these families, 39% made a positive change in the safety of their child's environment at the 2-week telephone follow-up. CONCLUSIONS: Caregivers receiving counseling by a PCP are more likely to provide a safe home environment for their children. Spanish-speaking patients are at particularly high risk of not receiving counseling. Of caregivers reporting unsafe practices during an unrelated emergency-department encounter, targeted counseling made a positive impact on behavior after discharge.