ED Stays Longer and Less Equitable for Kids Seeking Mental Health Care

(Reuters Health) – Increasingly, emergency department stays are longer and less equitable for U.S. kids seeking mental health care, a new study suggests.

An analysis of emergency department data from hospitals around the nation on visits by children aged 6 to 17 looking for help with mental health issues found that between 2005 and 2015, the number of hours spent in the ED grew. Moreover, this effect was felt most acutely by Hispanic and Latinx children, researchers report in Pediatrics.

“Kids are waiting way too long in emergency departments and this problem is getting worse rather than staying the same or getting better,” said lead author Dr. Katherine Nash, a fellow in the National Clinician Scholars Program at the Yale University School of Medicine and a pediatric hospitalist at the Yale-New Haven Hospital, in Connecticut.

“The mental health system and its failures are coming to a boiling point,” Dr. Nash said. “All the structural problems – lack of access to outpatient care, poor reimbursement, lack of inpatient beds, lack of investment and the impact of poverty on children’s health and wellness – all comes to a head in an acute crisis in the emergency department.”

Part of the problem is the lack of mental health providers in many emergency departments, Dr. Nash said. “They need to have 24-hour access to pediatric mental health providers,” she added. “We’ve learned you can do this through zoom or over the phone.”

For now, some institutions have found it useful to have a separate emergency department space for children to ease the throughput, Dr. Nash said. “They’re less chaotic for kids waiting for an evaluation,” she added.

To explore the prevalence of long emergency department stays, Dr. Nash and her colleagues turned to data from the National Hospital Medical Care Survey (NHAMCS), a cross-sectional survey of ambulatory and emergency department visits to U.S. hospitals (excluding federal, military and Veterans Affairs facilities).

The researchers included data on 36,125 ED visits for patients aged 6 to 17 between 2005 and 2015 in their analysis. After survey weighting, this represented 149,975,479 pediatric ED visits nationally, 4.9% of which were mental health visits.

Compared with non-mental health ED visits, lengths of stay for mental health visits during the study period were longer. Just 4.8% of non-mental health visits versus 21.2% of mental health visits lasted longer than six hours, 1.2% versus 7.7% lasted 12 hours or more, and 0.3% versus 1.9% lasted longer than 24 hours.

During the years covered by the study, rates of prolonged length of stay in the ED for non-mental health visits remained stable but increased dramatically for mental health visits: the average annual rate of ED length of stay greater than six hours for mental health visits rose from 16.3% to 24.6% (441,542 visits), and for length of stay greater than 12 hours, from 5.3% (86,791 visits) to 12.7% (227,010 visits).

Regression analysis revealed that visits for Hispanic/Lantinx children compared with those for non-Hispanic white children had more than twice the odds for a length of stay greater than 12 hours (odds ratio 2.74). There was no difference by payer type.

“The primary finding here is a progressive increase in the duration of emergency department visits for young people with mental health issues as compared to those with non-mental health conditions,” said Dr. Mark Olfson, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law at the Columbia University School of Medicine and professor of epidemiology at Columbia’s Mailman School of Public Health, in New York City. “I think there has, for many years, been a real shortage of not only inpatient psychiatric beds for young people but also rapidly available psychiatric outpatient beds.”

So, these children essentially end up being boarded in emergency departments while staff look for mental health care for them, said Dr. Olfson, who wasn’t involved in the study. “It’s really not a good situation for them,” he added. “It may be surprising to many people that a large proportion of emergency departments do not have a mental health professional there. Some have a mental health professional on call. But even then, it can take several hours to get an evaluation. Many are evaluated by someone in general medicine rather than a specialist in mental health.”

The problem is at least partly driven by finances, Dr. Olfson said. “If you look from the standpoint of the inpatient hospital, you don’t make as much money per day from mental health as you do for other kinds of medical and surgical services,” he added. “Over the last several years a number of hospitals have closed their psychiatric beds, and there’s always been a shortage for young people.”

The ED “can be a toxic environment for children with mental health issues,” Dr. Olfson said. “It’s noisy and loud.”

The current situation is “just delaying urgent care that these children need,” Dr. Olfson said. “Sometimes it’s better to admit them to the general medical-surgical floor to try to care for a child. It’s not optimal but it’s better than the ED.”

As for the disparities among Hispanic and Latinx children, some of that might come down to a lack of English proficiency in some parents, necessitating a translator, which can slow things up, Dr. Olfson said. This is a plausible explanation since other minorities, such as Black children, didn’t experience the same disparity.

SOURCE: https://bit.ly/2PCFidh and https://bit.ly/3dyXzQV Pediatrics, online April 5, 2021.

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