Impact of a Mental Health Screening Process in a Pediatric Emergency Department.

OBJECTIVE: The aim of this study was to describe how specific mental health-trained social workers can assist in the evaluations and follow-up of patients presenting with mental health concerns in the pediatric emergency department (ED). METHODS: Work was performed at a quaternary children's hospital ED with 95,000 annual ED visits across 2 locations. Patients requiring mental health services identified based on presenting complaint or from universal suicide screen were included. Emergency department team first evaluates the patients for medical screening and then consults a team of social workers specialized in acute mental health screening (AMHS). The team evaluates and provides recommendation for disposition and assists in plan completion. For patients not admitted, AMHS team makes 24- and 48-hour calls to ensure safety. We collected and analyzed the data on all eligible patients from September 2015 through June 2019 for (1) demographic information, (2) trends in number of consults to AMHS, (3) disposition plans and trends by year, and (4) frequency of follow-up phone calls. RESULTS: A total of 5950 patient visits were reviewed, for 4454 distinct patients. Most patients were 12 to 17 years of age, female, and White, with Medicaid being the predominant insurance. The most common chief complaint was suicidal ideation/plan/attempt. Self-referrals were the majority of assessments, and 59% of patients were already receiving mental health services. Median team response time was 19 minutes. There was an upward trend in consults. Psychiatric hospitalization was the most common disposition; more than 95% of the other visits had timely follow-up phone calls. CONCLUSION: Despite an increasing number of patients presenting to the ED with mental health crisis, safe and efficient management is possible with ED staff-social worker partnership. This approach can ensure that eligible patients receive consistent and evidence-based evaluations and can allow ED clinicians to respond to medical emergencies that require their attention.

Motivating Behavior Change in Parents for Suicide Prevention in the Midwest, USA.

Safe storage of lethal means is an evidence-based approach to suicide prevention that is underutilized. This naturalistic study investigated whether a presentation on parenting teenagers that includes education about safe storage of firearms and medications, paired with tools to enact change, can impact storage practices. Ten community presentations for parents were given between November 2018 and September 2019 in the Midwest region of the United States. Multiple topics pertinent to parenting adolescents were included with an emphasis on safe storage of firearms and medications to reduce suicide risk. Toolkits including medication storage boxes and cable gun locks were offered to help parents enact recommended changes. Surveys were completed prior to the presentation (T1), immediately following the presentation (T2), and 2 weeks after the presentation (T3). Five-hundred eighty-one parents comprised the initial study sample, of whom 410 (70.6%) completed the primary study endpoint. Generalized linear mixed models with and without worst-case imputation were used to evaluate changes in safe storage practices. Results suggested the odds of storing firearms in the safest manner possible increased 5.9 times (95% CI 2.6-13.5, p < 0.001) without imputation and increased 2.0 times (95% CI 1.1-3.4, p = 0.02) with the worst-case imputation. Among participants with unlocked medications at baseline, 56.5% reported they had disposed of old medications and 53.0% reported locking up bottles of medication by the primary study endpoint. This study provides preliminary evidence that safe storage education paired with tools for behavior change motivates parents to enact safe storage measures.

A refresher on Tourette syndrome.

Tourette Syndrome (TS) is recognized as a more common neurodevelopmental disorder than once thought. In this article we present an update on TS including the DSM-5 revised criteria, new findings in the genetics of TS, treatment advances such as new medications for tics and the use of new tools including Cognitive Behavioral Intervention for Tics (CBIT). We also explore supportive services for the ongoing care of patients using nursing education and family therapy.

Rates of Positive Suicide Screens in the Emergency Department and Outpatient Clinics at a Tertiary Care Children's Hospital.

PURPOSE: To provide guidance to hospitals that are developing suicide screening programs, we identified rates of positive screens across outpatient visits within a tertiary care children's hospital. METHODS: Suicide screening results from healthcare encounters occurring between February 2019 and January 2020 were estimated for ambulatory clinics (OP), urgent care (UC) clinics, and the emergency department (ED). RESULTS: Positive screens (95% confidence interval [CI]) occurred in 10.8% (10.6, 11.0)%) of visits overall. Rates of positive screens were 14.5 (14.1, 14.9)%, 9.9 (9.7, 10.1)%, and 9.3 (8.9, 9.7)% in the ED, OP, and UC, respectively. Rates of positive screens in outpatient clinics were highest in child abuse (33.4 (28.0, 39.2) %) and adolescent specialty (19.2 (17.3, 21.1) %). DISCUSSION: Some outpatient clinics had rates of positive suicide screens that surpass those seen in the ED. These findings could inform targeted suicide screening in hospital systems with limited resources to do universal screening.

Assessing the Validity of the Ask Suicide-Screening Questions in Black Youth.

BACKGROUND: Given the increasing rates of suicide and nonfatal suicide attempts among Black youth in the United States, it is crucial that screening tools are valid in identifying Black youth at risk of suicide. OBJECTIVE: This study assessed the validity of the Ask Suicide-Screening Questions (ASQ) among Black youth. METHODS: This analysis used pooled data from 3 ASQ validation studies of pediatric medical patients aged 10-21 years. All participants completed the ASQ and the gold standard Suicidal Ideation Questionnaire. RESULTS: Of the 1083 participants, 330 (30.5%) were non-Hispanic Black and 753 (69.5%) were non-Hispanic White. ASQ psychometric properties for Black and White participants were equivalent (sensitivity = 94% vs. 90.9%; specificity = 91.4% vs. 91.8%, respectively). CONCLUSIONS: There were no significant differences in ASQ psychometric properties between Black and White youth, indicating that the ASQ is valid for screening Black youth at risk of suicide.

Firearms Access among Pediatric Patients at Risk for Suicide.

BACKGROUND: Approximately 2,900 youth who die by suicide each year in the United States use a firearm. To inform lethal means safety counseling efforts, this study aimed to describe firearm access among youth deemed at risk for suicide in pediatric medical settings. METHODS: Youth who presented to one of four urban pediatric medical centers were screened for suicide risk and access to firearms. Suicide risk was determined by a positive screen on the Ask Suicide-Screening Questions (ASQ) tool. Firearm access was assessed via a structured questionnaire. RESULTS: This secondary analysis analyzed data from 1065 youth aged 10 to 17 years. Overall, 110 (10.3%) participants screened positive for suicide risk. Among those at risk, 28% (31/110) reported guns kept in or around their home, 8% (9/110) had access to a firearm, and 5% (6/110) reported that bullets were not stored separately from the guns. CONCLUSIONS: Over a quarter of youth at risk for suicide reported a firearm stored in or around their home. To ensure the safety of young people at risk for suicide, clinicians should assess whether youth have access to firearms and conduct lethal means safety counseling with youths, as developmentally appropriate, and their parent/caregivers.HIGHLIGHTS28% of pediatric patients deemed "at risk" for suicide in this study reported a firearm kept in or around their home.Among youth at risk for suicide, 8% reported having access to a firearm.These results add further evidence that it is important for clinicians to conduct lethal means safety counseling with patients and their families.

Suicide Risk in Adolescents During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic created high levels of psychological distress and may have increased suicide risk. METHODS: We used the 4-item Ask Suicide-Screening Questions (ASQ) to assess suicide risk among all patients 12 to 24 years of age at a children's hospital. We compared demographics, encounter type (telehealth or face-to-face [F2F]), and screening results from April to June 2020 (T2) to those from April to June 2019 (T1). RESULTS: Fewer patients were seen at T2 than T1 (17 986 vs 24 863). A greater proportion of visits at T2 were by telehealth (0% vs 43%). The rate of positive suicide screens was higher in T2 than in T1 (12.2% vs 11.1%, adjusted odds ration [aOR], 1.24; 95% confidence interval [CI], 1.15-1.35). The odds of a positive screen were greater for older patients (aOR of 1.12 for age in years; 95% CI, 1.10-1.14), female patients (aOR, 2.23; 95% CI, 2.00-2.48), patients with public versus private insurance (aOR, 1.88; 95% CI, 1.72-2.07), and lower for Black versus White patients (aOR, 0.85; 95% CI, 0.77-0.95). Rates of positive screens were highest among inpatients (20.0%), intermediate for emergency department patients (14.4%), and lowest in outpatient clinics (9.9%) (P < .05). CONCLUSIONS: Rates of positive suicide risk screens among adolescents rose in the pandemic's early months with differences related to sociodemographics and visit type. Changes in health care delivery highlight the complexities of assessing and responding to mental health needs of adolescents. Additional research might determine the effects of screening methods and patient populations on screening results.

Parent and Adolescent Thoughts About Suicide Risk Screening in Pediatric Outpatient Settings.

Suicide rates among adolescents in the United States continue to climb and many at-risk youths are undetected. Screening for suicidal thoughts has become the primary approach to identify those at risk, but no studies have assessed reactions to its deployment in pediatric outpatient settings. This mixed-method study assessed parents' and adolescents' thoughts about suicide risk screening in non-psychiatric, pediatric outpatient specialty settings.As part of a multi-site measurement validation study, adolescents (n = 269; ages 10-21) and parents (n = 246) at pediatric specialty clinics in the Midwest completed a survey regarding thoughts about suicide risk screening. Data were collected on tablet computers and transcribed verbatim. Three study team members independently coded transcripts of open-ended responses to identify major themes, and frequency data were analyzed using StataSE 15.1. Inter-rater agreement was substantial (Fleiss' Kappa ranged 75-86%).Parents (55% 41-50 years of age, 20% male, 80% White) and adolescents (Mean age = 14.3, 50% male, 77% White) agreed medical providers should screen adolescents for suicide risk (93% and 88%, respectively). Majority of parents indicated that the pediatric outpatient setting is appropriate for suicide risk screening. Major themes included the important role of providers in identifying at-risk youth, the potential for screening to prevent suicides, and concerns about iatrogenic risk and misdiagnosis.Most parents and adolescents support screening for suicide risk in pediatric outpatient settings. Nevertheless, some have concerns about the screening process and implications. As suicide risk screening becomes standard practice in adolescent care, it's critical to develop screening processes that maximize comfort and address concerns.

Implementing Universal Suicide Risk Screening in a Pediatric Hospital.

BACKGROUND: Health care providers are in a prime position to identify teens at risk for suicide, yet many do not. The research team developed and implemented a hospitalwide program to identify teens at elevated risk for suicide and connect them with services. METHODS: Screening was implemented at both locations of a pediatric hospital, including two emergency departments, three urgent care clinics, and ambulatory clinics. Patients aged 12 years and older presenting for care were screened for suicide risk using the Ask Suicide-Screening Questions (ASQ) in most settings, while the Columbia-Suicide Severity Rating Scale (C-SSRS) was used in mental health areas. A social worker responded to positive screens to complete a more thorough assessment and determine next steps. Social workers also completed outreach to patients in the weeks following a positive screen. Implementation began with pilot locations and expanded after refinements were made. Stakeholders provided screening recommendations, and education was provided prior to implementation. The cost of implementation was calculated based on the time screening required from nursing and social work. RESULTS: Review of the program focused on implementation fidelity, quality improvement, and trends among screening results. During the first year of screening, 138,598 screens were completed, and 6.8% of screens were positive for elevated risk. The annualized cost of the program was estimated to be $887,708.65 for personnel directly involved in screening and following up on positive screens. CONCLUSION: Early involvement of stakeholders and hospital leaders and a robust response plan were essential to successful implementation of this suicide-screening program.

Academic Medical Center Visits by Adolescents Preceding Emergency Department Care for Suicidal Ideation or Suicide Attempt.

OBJECTIVE: Suicide is a leading cause of death in children and adolescents, and healthcare encounters relating to suicidal ideation (SI) and suicide attempt (SA) are steadily increasing. Studies examining healthcare utilization by adolescents prior to emergency department (ED) evaluation for SI/SA are lacking and may guide risk assessment. METHODS: We performed a descriptive study of patients 10 to 18 years evaluated for SI/SA in either of our 2 academic, pediatric EDs between January 1 and December 31, 2016. We quantified and characterized healthcare encounters in the year preceding ED evaluation for SI/SA by obtaining data from the electronic health record. RESULTS: We identified 599 patients with an index ED visit for evaluation of SI/SA. Mean age was 14.1 years (SD 2.0 years); 69.8% female, 61.9% White, 55.4% publicly insured. Fifty-six percent (336/599) had at least one previous encounter within our healthcare system in the year preceding their index ED visit (median 3, maximum 40, IQR: 2, 7), most commonly among Black/African American and Hispanic adolescents. Among all patients we identified 1409 previous encounters, and 55.4% (780/1409) occurred within 6 months of the index ED visit. Sixty-two percent (880/1409) of previous encounters were to an outpatient clinic, primarily nonmental health, subspecialty clinics. CONCLUSIONS: Adolescent healthcare encounters in the year preceding ED evaluation for SI/SA occur in a variety of settings. A broad approach to suicide risk screening may improve opportunities for early identification and intervention.

Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics.

OBJECTIVE: Validate the Ask Suicide-Screening Questions (ASQ) with youth in outpatient specialty and primary care clinics. METHOD: This is a cross sectional instrument validation study assessing the validity of the ASQ with respect to the standard criterion, Suicidal Ideation Questionnaire (SIQ/SIQ Jr.). The sample included 515 English speaking youth ages 10-21 years old from outpatient specialty and primary care clinics. ASQ sensitivity, specificity, positive and negative predictive values (PPV/NPV), positive and negative likelihood ratios, c statistic and respective receiver operating characteristic curves were assessed. RESULTS: A total of 335 outpatient specialty and 180 primary care clinic participants completed the study. In outpatient specialty clinics, the ASQ showed a sensitivity of 100.0% (95% CI: 80.5-100.0%), specificity of 91.2% (95% CI: 87.5-94.1%), and NPV of 100.0% (95% CI: 98.7-100.0). In the primary care clinic, the ASQ showed a sensitivity of 100.0% (95% CI: 59.0-100.0%), specificity of 87.9% (95% CI: 82.0-92.3%), and NPV of 100.0% (95% CI: 97.7-100.0). Forty-five (13.4%) outpatient specialty clinic participants and 28 (15.6%) primary care clinic participants screened positive for suicide risk on the ASQ. CONCLUSIONS: The ASQ is a valid screening tool for identifying youth at elevated suicide risk in outpatient clinical settings.

Grief and Burnout in the PICU.

Doctors and nurses who work in PICUs often deal with emotionally difficult events. These events take a toll. They can cause long-term psychological problems that, if not addressed, can impair the ability of doctors and nurses to care for patients in a competent and compassionate manner. Furthermore, effective treatment is available. But there is a paradox. To get treatment, one must acknowledge the problem. Acknowledgment of the problem may not be encouraged, or may be discouraged and stigmatized, in the intensive care culture. This article describes a case in which a physician has classic signs of overwhelming grief and burnout, and it discusses the appropriate response.