Development and evaluation of a writing retreat program to build community and promote productivity in academic hospital medicine.

BACKGROUND: Scientific writing is a core component of academic hospital medicine, and yet finding time to engage in deeply focused writing is difficult in part due to the highly clinical, 24/7 nature of the specialty that can limit opportunities for writing-focused collaboration and mentorship. OBJECTIVE: Our objective was to develop and evaluate an academic writing retreat program. METHODS: We drafted a set of key retreat features to guide implementation of a 3-day, 2-night retreat program held within a 2 h radius of our hospital. Agendas included writing blocks ranging from 45 to 90 min interspersed with breaks and opportunities for feedback, exercise, and preparing meals together. After each retreat, we distributed an evaluation with multiple choice and free text response options to characterize retreat helpfulness and later gathered data on the status of each paper and grant worked on. RESULTS: We held 4 retreats between September 2022 and October 2023, engaging 18 faculty and fellows at a cost of $296 per attendee per retreat. In evaluations, nearly 80% reported that the retreat was extremely helpful, and comments praised the highly mentored environment, enriching community of colleagues, and release from commitments that get in the way of writing. Of the 24 papers attendees worked on, 12 have been accepted and 6 are under review. Of the 4 grant proposals, 2 are under review. CONCLUSIONS: We implemented a low-cost, productive writing retreat program that attendees reported was helpful in supporting deep work and represented a meaningful step toward building a community centered around academic writing.

Impact of mental health boarding on clinicians at a children's hospital: A qualitative analysis.

BACKGROUND: The child and adolescent mental health boarding crisis (i.e., prolonged stays in acute care hospitals for patients awaiting mental health treatment) continues to challenge acute care hospital staff and resources. We sought to understand clinician's experiences while caring for patients experiencing mental health boarding. METHODS: We conducted semistructured qualitative interviews with clinicians who care for patients experiencing mental health boarding in an acute care freestanding children's hospital with no inpatient psychiatric unit. We used an inductive approach to determine interview themes and major findings. RESULTS: The study included 48 clinician participants from diverse specialties, including 13 social workers, 11 nurses, five psychiatric technicians, six pediatric residents, four attending pediatric hospitalists, four attending psychiatrists, one psychologist, and four other mental health specialists. We identified emergent themes in five domains: (1) frustrations with the mental healthcare system, (2) lack of training in mental healthcare skills, (3) feelings of helplessness, (4) ineffectiveness of medical model of care during mental health boarding, and (5) resilience and support factors. CONCLUSIONS: Caring for patients with mental health boarding has negative effects on clinicians, and health system efforts to prevent boarding could improve workforce retention and reduce burnout.

Adolescent, Parent, and Provider Perceptions of a Predictive Algorithm to Identify Adolescent Suicide Risk in Primary Care.

OBJECTIVE: To understand adolescent, parent, and provider perceptions of a machine learning algorithm for detecting adolescent suicide risk prior to its implementation primary care. METHODS: We conducted semi-structured, qualitative interviews with adolescents (n = 9), parents (n = 12), and providers (n = 10; mixture of behavioral health and primary care providers) across two major health systems. Interviews were audio recorded and transcribed with analyses supported by use of NVivo. A codebook was developed combining codes derived inductively from interview transcripts and deductively from implementation science frameworks for content analysis. RESULTS: Reactions to the algorithm were mixed. While many participants expressed privacy concerns, they believed the algorithm could be clinically useful for identifying adolescents at risk for suicide and facilitating follow-up. Parents' past experiences with their adolescents' suicidal thoughts and behaviors contributed to their openness to the algorithm. Results also aligned with several key Consolidated Framework for Implementation Research domains. For example, providers mentioned barriers inherent to the primary care setting such as time and resource constraints likely to impact algorithm implementation. Participants also cited a climate of mistrust of science and health care as potential barriers. CONCLUSIONS: Findings shed light on factors that warrant consideration to promote successful implementation of suicide predictive algorithms in pediatric primary care. By attending to perspectives of potential end users prior to the development and testing of the algorithm, we can ensure that the risk prediction methods will be well-suited to the providers who would be interacting with them and the families who could benefit.

Characteristics, disposition, and outcomes of children hospitalized for mental health boarding at a children's hospital.

Increasingly, youth experiencing mental health crises present to acute care medical hospitals and "board" on medical units due to inpatient psychiatric bed shortages. We conducted a retrospective cohort study of children experiencing mental health boarding at a US children's hospital from October 2020 to September 2022. We examined associations between patients' characteristics and their disposition and outcomes. Our cohort included 1891 boarding hospitalizations: 53.9% transferred to an inpatient psychiatric hospital and 46.1% discharged home. Characteristics associated with not being transferred to an inpatient psychiatric hospital included age <13 years (adjusted odds ratio [aOR] 0.6; 95% confidence interval [CI]: 0.4-0.7), disruptive or aggressive behavior (aOR 0.6; 95% CI: 0.4-0.8), psychosis (aOR 0.5; 95% CI: 0.3-0.8), COVID-19 infection (aOR 0.3; 95% CI: 0.2-0.6), or a complex chronic medical condition (aOR 0.8; 95% CI: 0.6-1.0). Our findings suggest that certain populations of children experiencing mental health boarding face disparate access to inpatient psychiatric care.

Factors influencing agitation, de-escalation, and physical restraint at a children's hospital.

BACKGROUND: Children hospitalized in medical hospitals are at risk of agitation. Physical restraint may be used to maintain patient and staff safety during de-escalation, but physical restraint use is associated with physical and psychological adverse events. OBJECTIVE: We sought to better understand which work system factors help clinicians prevent patient agitation, improve de-escalation, and avoid physical restraint. DESIGN, SETTING, AND PARTICIPANTS: We used directed content analysis to extend the Systems Engineering Initiative for Patient Safety model to clinicians working with children at risk for agitation at a freestanding children's hospital. INTERVENTION, MAIN OUTCOME, AND MEASURES: We conducted semistructured interviews to examine how five clinician work system factors affected patient agitation, de-escalation, and restraint: person, environment, tasks, technology and tools, and organization. Interviews were recorded, transcribed, and analyzed until saturation. RESULTS: Forty clinicians participated in this study, including 21 nurses, 15 psychiatric technicians, 2 pediatric physicians, 1 psychologist, and 1 behavior analyst. Work system factors that contributed to patient agitation were medical tasks like vital signs and the hospital environment including bright lights and neighboring patients' noises. Supports that helped clinicians de-escalate patients included adequate staffing and accessible toys and activities. Participants indicated that organizational factors were integral to team de-escalation, drawing connections between units' teamwork and communication cultures and their likelihood of successful de-escalation without the use of physical restraint. CONCLUSION: Clinicians perceived that medical tasks, hospital environmental factors, clinician attributes, and team communication influenced patients' agitation, de-escalation, and physical restraint. These work system factors provide opportunities for future multi-disciplinary interventions to reduce physical restraint use.

Nurse Education and Hospital Readmissions for Children With and Without a Mental Health Condition.

OBJECTIVES: In adults, receiving care in a hospital with more baccalaureate-prepared nurses improves outcomes. This relationship is magnified in adults with serious mental illness or cognitive impairment. Whether the same is true in children with and without a mental health condition is unknown. The study purposes were to determine 1) whether the proportion of baccalaureate-prepared nurses affected the odds of readmission in children; and 2) whether this relationship differed for children with a mental health condition. PATIENTS AND METHODS: We linked cross-sectional data from the 2016 Healthcare Cost and Utilization Project State Inpatient Databases, the RN4CAST-US nurse survey in Florida, and the American Hospital Association. Inclusion criteria were ages 3 to 21 years. Mental health conditions were defined as psychiatric or developmental/behavioral diagnoses. These were identified using the Child and Adolescent Mental Health Disorders Classification System. We used multivariable, hierarchical logistic regression models to assess the relationship between nurse training and readmissions. RESULTS: In 35 081 patients admitted to 122 hospitals with 4440 nurses, 21.0% of patients had a mental health condition and 4.2% had a 7-day readmission. For individuals without a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 8.0% lower odds of readmission (odds ratio = 0.92, 95% confidence interval = 0.87-0.97). For those with a mental health condition, each 10% increase in the proportion of baccalaureate-prepared nurses was associated with 16.0% lower odds of readmission (odds ratio = 0.84, 95% confidence interval = 0.78-0.91). CONCLUSIONS: A higher proportion of baccalaureate-educated nurses is associated with lower odds of readmission for pediatric patients. This association has a larger magnitude in patients with a mental health condition.

"Treat Them Like a Human Being They are Somebody's Somebody": Providers' Perspectives on Treating Patients in the Emergency Department After Self-Injurious Behavior.

To understand ED providers' perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to "What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?" were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.

Pediatric emergency departments' readiness for change toward improving suicide prevention: A mixed-methods study with US leaders.

Objective: To assess pediatric emergency departments' (PEDs) current suicide prevention practices and climate for change to improve suicide prevention for youth. Methods: We conducted an explanatory, sequential mixed-methods study. First, we deployed a national, cross-sectional survey of PED leaders identified through publicly available data in Fall 2020, and then we conducted follow-up interviews with those who expressed interest. The survey queried each PED's suicide prevention practices and measured readiness for change to improve suicide prevention practices using questions scored on a 5-point Likert scale. Interviews gathered further, in-depth descriptions of PEDs' practices and culture. Interviews were audio-recorded, transcribed verbatim, and analyzed using a rapid analysis approach. Results: Of 135 PED directors eligible to complete the survey, 64 responded (response rate 47%). A total of 64% of PEDs had a mental health specialist available 24 hours/day, 7 days/week; 80% reported practicing mental health disposition planning, and 41% reported practicing psychiatric medication management. Altogether 91% of directors agreed or strongly agreed that their PED had a positive culture and 92% agreed/strongly agreed that their PED was ready for change. However, 31% disagreed/strongly disagreed that their PED had tools for evaluation and quality measurement. Resources needed for change (including budget, staffing, training, and facilities) varied across institutions. Interviews with our convenience sample of 21 directors revealed varying suicide prevention practices and confirmed that standardization, evaluation, and quality improvement initiatives were needed at most institutions. Leaders reported a high interest in improving care. Conclusions: PED leaders reported high motivation to improve suicide prevention services for young people, and reported needing quality improvement infrastructure to monitor and guide improvement.

Acute medical workup for new-onset psychosis in children and adolescents: A retrospective cohort.

No consensus exists about which medical testing is indicated for youth with new-onset psychotic symptoms. We conducted a chart review of youths aged 7-21 years who were medically hospitalized for workup of new-onset psychotic symptoms from January 2017 through September 2020 in a free-standing children's hospital. The sample included 131 patients. At discharge, 129 (98.5%; 95% confidence interval [CI]: 94.5-99.8) were diagnosed with a primary psychiatric condition, 1 was diagnosed with levetiracetam-induced psychosis, and 1 with seronegative autoimmune encephalitis. Notably, 33 (25.2%; 95% CI: 18.0-33.5) had incidental findings unrelated to psychosis, 14 (10.7%; 95% CI: 6.0-17.3) had findings that required medical intervention but did not explain the psychosis, 12 (9.2%; 95% CI: 4.8-15.5) had a positive urine drug screen, and 4 (3.1%; 95% CI: 0.8-7.6) had a neurological exam consistent with conversion disorder. In conclusion, extensive medical testing in the acute setting for psychosis had a low yield for identifying medical etiologies of new-onset psychotic symptoms.

Mental Health and COVID-19 in Pediatric Emergency Departments: Perspectives From Directors.

PURPOSE: The aim of this study is to understand pediatric emergency department (PED) directors' perspectives on the COVID-19 pandemic's effect on PED visits for mental health concerns. METHODS: Semi-structured phone interviews were conducted with a national convenience sample of PED directors. Interviews were recorded, transcribed verbatim, and analyzed using rapid content analysis. RESULTS: Twenty-one PED directors from 18 states were interviewed. Directors perceived an increased volume of mental health visits and higher patient acuity. Some PEDs innovatively adapted services but were also met with new barriers in providing care due to increased use of personal protective equipment and required COVID-19 testing. Transfer to inpatient psychiatric units was more complicated due to reduced overall bed capacity and the need for a negative COVID test. DISCUSSION: The COVID-19 pandemic strained an already fragile pediatric emergency mental health system. Building infrastructure for adaptations and mental health service reserve capacity could help ensure proper care for pediatric patients with mental health crises during future public health emergencies.

Assessing Suicide Risk in a Pediatric Outpatient Behavioral Health System: A Quality Improvement Report.

Introduction: Standardized suicide risk assessment improves the detection of individuals at risk of suicide. We conducted a quality improvement initiative in a system of outpatient behavioral health practices affiliated with a free-standing children's hospital to implement standardized suicide risk assessment for new patients. Methods: Clinicians received education in suicide risk assessment and were trained to use an evidence-based suicide risk assessment tool, the Columbia Suicide Severity Rating Scale (C-SSRS). We standardized workflow processes and integrated the C-SSRS in the electronic health record with a feature to communicate instances of elevated risk across care teams through a problem list. We analyzed C-SSRS responses and adherence to standardized processes and compared the percentage of patients with a suicide-related item on the problem list before and after implementation. We assessed clinician knowledge through a survey. All patients with identified suicide risk received treatment to reduce their risk of suicide in the context of usual care. Results: For 3,972 new patient visits occurring postimplementation (November 2016-December 2018), the average monthly adherence to the standardized process was 97.7%. The mean monthly incidence of nonspecific active suicidal thoughts was 16%, aborted suicide attempts were 2%, and actual suicide attempts were 3%. The mean monthly incidence of a suicide-related item documented on the problem list was 5.66% in the postimplementation period compared with 1.47% in the 1-year preimplementation. Clinicians demonstrated statistically significant increases in knowledge about suicide risk factors and assessment. Conclusions: Standardization of suicide risk assessment processes improved detection and documentation of suicide risk in a pediatric outpatient behavioral health setting.

Caregiver experiences during their child's acute medical hospitalization for a mental health crisis.

Adolescents in the United States are increasingly seeking treatment for mental health crises in emergency departments and general medical hospitals. Medical needs are often addressed quickly, yet youth remain hospitalized because further psychiatric treatment is not immediately available. We sought to better understand the experiences of caregivers whose children are "boarding" in a medical hospital while awaiting inpatient psychiatric treatment. We conducted semi-structured interviews with caregivers who were recruited, enrolled, and interviewed during their child's hospital stay. Interviews were audio-recorded, transcribed verbatim, and thematic analysis was facilitated by NVivo 12. Fourteen caregivers enrolled in the study. Themes that emerged included positive hospital and provider experiences; frustration with the medical and mental health care systems; information needs; fears about inpatient psychiatric units; practical challenges and emotional needs; difficulties with caregiver-child communication; difficulties with clinician-caregiver communication; and need for self-care and support. While many caregivers felt positively about the overall experience at the hospital, they also wished for more information about their child's treatment plan and future, as well as social support, emotional comfort for themselves, and self-care skills and resources. Their experiences illuminate ways in which clinical practice can ameliorate concerns and alleviate stress of caregivers related to their child's mental health crisis.

Depression and Anxiety Symptoms During and After Pediatric Asthma Hospitalization.

OBJECTIVES: Depression and anxiety are common in children with asthma, and asthma hospitalization is an underused opportunity to identify mental health concerns. We assessed depression and anxiety symptoms during asthma hospitalization and 1 to 2 months post discharge. METHODS: This prospective cohort study included children aged 7 to 17 years who were hospitalized for asthma exacerbation. Participants completed the self-report PROMIS (Patient-Reported Outcomes Measurement Information System) depression and anxiety symptom scales (T score mean = 50, SD = 10) during hospitalization and 1 to 2 months after discharge. Higher scores indicate more symptoms and/or greater severity. We compared patients' scores during hospitalization and at follow-up using paired t tests and examined individual patients' depression and anxiety symptom trajectories using a Sankey diagram. RESULTS: Among 96 participants who completed the study, 53% had elevated symptoms of depression, anxiety, or both either during hospitalization or after discharge. During hospitalization, 38% had elevated depression symptoms and 45% had elevated anxiety symptoms. At postdischarge follow-up, 18% had elevated depression symptoms and 20% had elevated anxiety symptoms. We observed all possible symptom trajectories: symptoms during hospitalization that persisted (especially if both depression and anxiety symptoms were present), symptoms that resolved, and symptoms that were present at follow-up only. CONCLUSIONS: Just more than half of youth hospitalized for asthma exacerbation experienced depression and/or anxiety symptoms during hospitalization or at follow-up. Patients who had both depression and anxiety symptoms during hospitalization were the most likely to have persistent symptoms at follow-up. Screening at both time points may be useful to identify mental health symptoms.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders.

STUDY OBJECTIVE: We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts. METHODS: We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach. RESULTS: Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients. CONCLUSION: Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit.

BACKGROUND AND OBJECTIVES: To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns. METHODS: We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day. RESULTS: The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001). CONCLUSIONS: Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

Mental Health Service Use Before and After a Suicidal Crisis Among Children and Adolescents in a United States National Medicaid Sample.

INTRODUCTION: Mental health follow-up after an emergency department (ED) visit for suicide ideation/attempt is a critical component of suicide prevention for young people. METHODS: We analyzed 2009 to 2012 Medicaid Analytic EXtract for 62,139 treat-and-release ED visits and 30,312 ED-to-hospital admissions for suicide ideation/attempt among patients ages 6 to 17 years. We used mixed-effects logistic regression models to examine associations between patients' health care utilization prior to the ED visit and likelihood of completing a 30-day mental health follow-up visit. RESULTS: Overall, for treat-and-release ED visits, 49% had a 30-day follow-up mental health visit, and for ED-to-hospital admissions, 67% had a 30-day follow-up mental health visit. Having a mental health visit in the 30 days preceding the ED visit was the strongest predictor of completing a mental health follow-up visit (ED treat-and-release: adjusted odds ratio [AOR] 11.01; 95% confidence interval [CI] 9.82-12.35; ED-to-hospital AOR 4.60; 95% CI 3.16-6.68). Among those with no mental health visit in the 30 days preceding the ED visit, only 25% had an ambulatory mental health follow-up visit. Having a general health care visit in the 30 days preceding the ED visit had a much smaller association with completing a mental health follow-up visit (ED treat-and-release: AOR 1.17; 95% CI 1.09-1.24; ED-to-hospital AOR 1.25; 95% CI 1.17-1.34). CONCLUSIONS: Young people without an existing source of ambulatory mental health care have low rates of mental health follow-up after an ED visit for suicide ideation or attempt, and opportunities exist to improve mental health follow-up for youth with recent general health care visits.

Trends in Length of Stay and Readmissions in Children's Hospitals.

BACKGROUND AND OBJECTIVES: Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals. METHODS: Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix. RESULTS: Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased (P < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, P < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; P = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; P < .001). CONCLUSIONS: Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.