Practice Patterns in Pediatric Emergency Psychiatry

Educational Objectives

The goal of this program is to improve management of pediatric emergency in psychiatry. After hearing and assimilating this program, the clinician will be better able to:

1. Identify differences in engagement levels associated with liaison activities, direct care delivery, and research in a survey assessing practice patterns in pediatric emergency psychiatry.

Summary

Introduction: an ongoing survey that is modeled after a similar study in pediatric consultation-liaison psychiatry (Shaw et al [2016]) aims to understand current practice patterns, including staffing models, service delivery, population served, and reimbursement, in pediatric emergency psychiatry; the results of this survey may help understand best practices and inform future practice

Methods: 42-questions Qualtrics survey; 70 participant sites have been enrolled so far; results of 16 partially or fully completed surveys are available now

Initial results: a large proportion of respondents were child psychiatrists; a higher proportion of sites were from Northeast; most sites were urban, large, academic sites with a dedicated children’s hospital

Access to inpatient psychiatry unit: out of 13, 9 sites provided direct access; they reported a lack of specialty services and were discharging patients early; lack of direct access significantly affected boarding

Service delivery: all sites provided consultation; a few sites provided integrated space in the emergency department (ED) or a standalone psychiatric ED; some sites served patients ≤21 yr of age; the proportion of primary mental health (PMH) presentation to total ED volume was typically 2% to 6% (≤30% in one site); the rates of PMH admission varied widely

Boarding: patients primarily boarded in the ED setting; time limits for transitioning out of ED has been 24 to 48 hr in sites; most of the sites have been boarding their patients in the ED per the Joint Commission definition (4 hr); most patients received daily follow-up from psychiatry team and from their nonpsychiatry ED colleagues; the nonpsychiatric follow-up was more frequent (not uniformly); the average length of stay of patients presenting to ED with PMH concerns was >24 hr in some sites

Staffing: primarily composed of child psychiatrists, social worker, and child psychiatry fellows, but it was highly heterogeneous; sites uniformly reported increase in staffing resources

Education: fellows with varying experience (average, 1-2 mo) and postgraduate year 2 residents were present in most sites; medical students (duration, 2-4 wk) were present in a few sites; other nonpsychiatric trainees and allied professionals were also involved

Primary provider: emergency department (ED) physician was the primary provider (91%); the role of social worker in the ED was variable

Delivery of care: typically, in-person care was available during weekdays (including evenings) and weekend days; overnight coverage and weekend evenings were highly variable (eg, in-person, hybrid, telepsychiatry, brief telephonic emergency support)

Service activity: most sites have reported high level of engagement in direct care delivery and coordination; moderate level of activity in liaison activities and education reported; according to reports, there is low level of activity in community outreach and research; half the sites have reported no activity in research

Services offered: most sites provide diagnostic evaluation, medication management, referral for MH treatment, transfer to another psychiatric facility, and psychoeducation; most sites do not provide family or group therapy

Medical conditions: predominantly self injury or suicide, behavioral dysregulation associated with autism, and aggression or disruptive behavior; others included eating and anxiety disorders; psychosocial concerns, issues around foster care, and aggression consumed most of the time

Screening: suicide, abuse or neglect, and substance use were routinely screened; standardized protocols were mostly available for suicide and aggression

Reimbursement and funding: commonly, professional billing, followed by hospital-based funding and fee-for-service; primary source of funding is hospital based; shift-based model was common, followed by relative value units-based model; increase in funding was reported by 7 sites

Readings

Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9):e2233964. doi:10.1001/jamanetworkopen.2022.33964; Shaw RJ, Pao M, Holland JE, et al. Practice patterns revisited in pediatric psychosomatic medicine. Psychosomatics. 2016;57(6):576-585. doi:10.1016/j.psym.2016.05.006.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Malas was recorded at the 13th Annual National Update on Behavioral Emergencies, held December 8-9, 2022, in Paradise Valley, AZ, and presented by the American Association for Emergency Psychiatry. For more information about upcoming CME activities from this presenter, please visit Emergencypsychiatry.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

PS520802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.