Across the nation, emergency departments (ED) are seeing and feeling an increase in pediatric mental health care needs. Seattle Children’s is no exception. In May 2016, the hospital had 247 patients present for a primary mental health concern. In May 2019, the hospital had 374 patients—a 66% increase in three years.
These children and adolescents arrive at the ED with suicidal thoughts, behaviors, tendencies for self-directed violence, aggression and a loss of function related to mental illness. With this increase in volume comes an increase in acuity: actively suicidal patients and risk of elopement. Here’s how Seattle Children’s is making efforts to improve care for mental health patients in the ED.
Screen all patients for suicide
The National Institute of Mental Health (NIMH) recommends universal suicide screening, so Seattle Children’s adopted the Zero Suicide Initiative. All patients ages 10 and up who are not in medical distress and are developmentally able to answer questions are screened for current and past suicidality. The ED nurses use the ASQ, (Ask Suicide Screening Questions) a validated tool for this age group, upon presentation to the ED or upon admission to inpatient units.
To date, Seattle Children’s has a 90% screening compliance rate. More than 4,500 kids have been screened, with 10% endorsing passive suicidal ideation. These patients meet with a mental health provider for further assessment and disposition recommendations. About 1% have reported current or active suicidal ideation with their medical presentation. Disposition for these patients include the same high-level quality of care that patients presenting for a primary mental health concern receive: assessment, psych education, crisis prevention planning and resources in the community.
Saaliha Nawaz, M.S.N., RN, worked in the ED before and after implementation of the suicide screening. “Kids are receptive to answering questions and families are receptive to giving their kids privacy,” she says. “I’ve never had a bad experience with the questionnaire.”
Dedicate duties to a pediatric mental health specialist
At Seattle Children’s, an emergency mental health evaluation team consists of two providers: the evaluator who determines if criteria is met for inpatient stabilization; and a pediatric mental health specialist from the inpatient behavioral medicine unit. The mental health specialist assists with behavior management, psych education, and crisis prevention planning if the patient discharges.
More than 35 pediatric mental health specialists from the inpatient behavioral and psychiatric medicine unit have been trained as ED navigators who lead families through the mental health care process and assist with communication and updates between the team. Since implementation, two navigators have joined the ED mental health team for full-time evening shift coverage and continuity. Data shows that despite increases in volume, length of stay in the ED has remained the same and though more patients attempt elopement, only 1% or less are successful.
Alex Bonn, navigator, worked on the inpatient psychiatric unit at Seattle Children’s before moving to the emergency mental health team full time. “We implemented a system and created a team that facilitates a smooth experience,” she says. “It orients the family to the emergency mental health process and then steps back in after the evaluation to create a comprehensive crisis plan or facilitate admission. We are bridging gaps in this system. Kids feel heard and families feel seen.”
Enhance collaboration and training
A security and patient watch department already had a presence in the ED, so the group enhanced their training with a two-hour mandatory mental health patient watch training class provided by ED mental health staff. Since then, the hospital added competency reviews and regulatory audits for patient watch staff.
Recently, the mental health team conducted classes for ED nurses on the functions of behavior, de-escalation and trauma-informed care. To bridge the divide between mental health and medical teams, an interdisciplinary ED mental health committee composed of representatives from nursing leadership, medical leadership, psych leadership, security, mental health, nursing and patient watch staff meet every six weeks to address interventions related to current safety needs, risk assessments, volumes and behavior management.
Connect beyond the hospital
Seattle Children’s is offering staff training and education on personal awareness, behavior and aggression management and current mental health trends to hospitals in the region. In addition to outreach in the health care environment, shelters that support women, children and immigrants have requested and received training for their staff.
The latest numbers from the Centers for Disease Control and Prevention show suicide is the second leading cause of death of 10- to 34-year-olds. “These are the kids that keep me up at night,” says Russ Migita, M.D., ED clinical director. “We must not only meet this rising need but meet it efficiently with multifaceted efforts and with sensitivity.”