Suicidality and hospitalization as cause and outcome of pediatric psychiatric emergency room visits.

The aim of this study was to identify predictors of suicidality in youth presenting to a pediatric psychiatric emergency room service (PPERS). To this end, we conducted a retrospective cohort study of youth aged <18 years consecutively assessed by a PPERS 01.01.2002-12.31.2002, using a 12-page semi-structured institutional evaluation form and the Columbia Classification Algorithm for Suicide Assessment. Multivariate regression analyses were conducted to identify correlates of suicidal thoughts and attempts/preparation and their relationship to outpatient/inpatient disposition. Of 1,062 youth, 265 (25.0%) presented with suicidal ideation (16.2%) or attempt/preparation (8.8%). Suicidal ideation was associated with female sex, depression, adjustment disorder, absent referral by family/friend/self, school referral, precipitant of peer conflict, and no antipsychotic treatment (p < 0.0001). Suicidal attempt/preparation was associated with female sex, depression, lower GAF score, past suicide attempt, precipitant of peer conflict, and no stimulant treatment (p < 0.0001). Compared to suicidal attempt/preparation, suicidal ideation was associated with school referral, and higher GAF score (p < 0.0001). Of the 265 patients with suicidality, 58.5% were discharged home (ideation = 72.1% vs. attempt/preparation = 33.7%, p < 0.0001). In patients with suicidal ideation, outpatient disposition was associated with higher GAF score, school referral, and adjustment disorder (p < 0.0001). In patients with suicidal attempt/preparation, outpatient disposition was associated with higher GAF score, lower acuity rating, and school referral (p < 0.0001). Suicidality is common among PPERS evaluations. Higher GAF score and school referral distinguished suicidal ideation from suicidal attempt/preparation and was associated with outpatient disposition in both presentations. Increased education of referral sources and establishment of different non-PPERS evaluation systems may improve identification of non-emergent suicidal presentations and encourage more appropriate outpatient referrals.

Frequency and correlates of inappropriate pediatric psychiatric emergency room visits.

BACKGROUND: Despite increasing pediatric psychiatric emergency room service (PPERS) visits, data are lacking regarding visit characteristics and appropriateness. METHOD: This retrospective cohort study consecutively assessed youngsters aged < 18 years between January 1 and December 31, 2002, utilizing data from a 12-page semistructured institutional evaluation form. Appropriateness, severity, acuity, and harm potential of PPERS visits were rated on a Likert scale. RESULTS: Of 1,062 PPERS patient visits (mean +/- SD age: 13.5 +/- 3.1 years, 51.1% male, and 51.2% white), 305 (28.7%) led to hospitalization. Although most patients (68.7%) were in outpatient care, only 21.9% sought and 11.5% completed an outpatient evaluation prior to reaching the emergency room. As many as 34.4% of PPERS visits were somewhat/very inappropriate (optimal care: outpatient evaluation/treatment, even if delayed), 26.6% were somewhat appropriate/neutral (best served by outpatient evaluation/treatment, but timely appointment unavailable), and only 39.0% were fully appropriate. Main reasons for inappropriate PPERS visits were direct emergency room referral from school (P = .0056) or mental health provider (P = .0438) without prior psychiatrist evaluation, or unavailable appointment (P = .0304). Multivariate predictors of inappropriate PPERS visits (r(2) = .296, P < .0001) included current Global Assessment of Functioning score > 48 (P < .0001), absent suicidal ideation/attempt (P < .0001), low harm potential (< 4.4, P < .0001) and severity (< 4.8, P = .0136) (1- to 7-point scale) of presenting complaint, and absent psychosis (P = .0008). CONCLUSIONS: Over one third of PPERS visits were inappropriate, characterized by better functioning, low harm potential or severity of presenting complaint, and absent suicidality or psychosis. Development of and improved access to urgent child and adolescent psychiatric outpatient care services in the community and referral agent educational programs may minimize inappropriate PPERS visits.