Exploring differences in the clinical management of pediatric mental health in the emergency department.

OBJECTIVE

: We examine psychiatric and pediatric clinical management of pediatric mental health in the emergency department (ED).

METHODS

: We conducted a retrospective review of health care delivery with a random sample of all pediatric mental health presentations (≤18 years) to 2 urban tertiary care EDs between 2004 and 2006 (N = 580).

RESULTS

: The EDs differed significantly in services offered. General emergency medicine-trained physicians provided care at 1 site (54.6%) with a number of visits also managed by a psychiatric crisis team (45.4%). Care at the other ED was delivered by pediatric emergency medicine-trained physicians (99.4%) with no regular on-site psychiatric services. The most common assessment provided across sites and all presentations was for suicidality (66.2%). After controlling for potential confounders, receipt of clinical assessment for homicidality, mood, or reality testing differed between EDs (P = 0.044, P = 0.006, and P = 0.002) with more assessments documented at the psychiatric-resourced ED. Brief counseling was lacking for visits (absence of documentation: 56.1% pediatric-resourced, 23.1% psychiatric-resourced ED); there was no evidence of site differences in provision. More psychiatric consultation was provided at the psychiatric-resourced ED (34.1% vs 27.4%, P = 0.030). Discharge recommendations were lacking in both EDs but were more incomplete for pediatric-resourced ED visits (P = 0.035).

CONCLUSIONS

: Consistent and comprehensive clinical management of pediatric mental health presentations was lacking in EDs that had pediatric and psychiatric resources. Prospective evaluations are needed to determine the effect of current clinical ED practices on patient and family outcomes, including symptom reduction and stress, as well as subsequent system use.