Children and young people in the United States are experiencing soaring rates of suicide, self-harm, anxiety and depression. In the U.S., Wisconsin has the fifth-highest increase in adolescent self-harm and attempted suicide, and the emergency department (ED) at Children’s Wisconsin has felt the effects of those numbers.
“From 2020 to 2021, we saw a 60% increase in kids who had attempted suicide,” says Michelle Pickett, M.D., M.S., an emergency room physician. “And so far, our 2022 numbers are on par with 2021.” Pickett says she sees at least two children every shift who are in the emergency department for suicidal ideation or attempt.
Over the past few years, Children’s Wisconsin has invested in solutions for the crisis, including a $2.5 million grant from The United Health Foundation and a $20 million gift from the Yabuki Family Foundation. Here are three initiatives the hospital has implemented in its ED.
1. Crisis response team
In 2020, Children’s Wisconsin established a crisis response team dedicated to the ED composed of a psychiatrist, three mental and behavioral health social workers, a mental and behavioral health navigator, and a supervisor. The team is available around the clock and facilitates consultations, resources, referrals and follow-ups. “They have been amazing,” Pickett says. Pickett often collaborates with the psychiatrist on plans and medication for patients who frequently return to the ED.
The team expected to support around 800 children a year, but they have exceeded that number every year, with 1,400 kids receiving support in 2021.
One essential part of this team’s role is the follow-up after patients are discharged. Patients and families are guided by the crisis response team’s navigator, who ensures they’re connected with the necessary resources and relationships with providers and services.
“Children's Wisconsin is the only level one trauma center, so no matter who your pediatrician is, you're going to come here if you have a crisis,” Pickett says. “The navigator ensures the follow-ups with the child's pediatrician are done and shares those community resources so that when patients and families leave our emergency department, they're equipped.”
2. Mental health screening for all patients
Pickett adopted a suicide screening questionnaire to give to every child 10 years and older in the ED. The screening asks four questions to assess the patient’s level of risk—plus one follow-up if the patient answers yes. The questions focus on whether the patient has had or is having thoughts of self-harm.
Patients answer the questions privately on an iPad. “Normally the tool is developed to be asked verbally, but we know that kids aren't always answering honestly when they're asked, especially when there are other people in the room,” Pickett says.
Responses are recorded in the patient’s electronic heath record (EHR). When the provider opens the patient’s chart, they get an alert and can see the answers. After talking with the patient and parent, the provider decides whether to consult the department’s social workers who are available 24/7.
Since 2018, more than 36,000 patients have received the screening, and about 5,800 (16%) have screened positive, meaning they answered yes to one of the questions. Of those positive screens, 31% have needed the social work consultation to facilitate resources. Some of the positives were children who visited the ED for an unrelated issue. “We have caught kids who came in for unrelated problems, whether it was a sprained ankle or ear pain,” Pickett says. “They were found to be acutely suicidal and needed to get transferred to an inpatient facility immediately.”
One added benefit of these screenings is fostering conversations between patients and their families about mental health. “Even if the child screens negative, it opens that communication with parents. Sometimes the parents are completely unaware that their child was having these thoughts,” Pickett says. “My hope is that they continue the conversation and the child feels like they are more able to talk to their parents.”
3. Mental health walk-in clinic
Many parents of children going through a mental health crisis go to the emergency room out of a loss for what else to do or where else to go. To provide an immediate resource for these families, and to ease the burden on the ED, Children’s Wisconsin opened an urgent mental health walk-in clinic. “It’s another outlet we’ve created to help in this mental health care crisis,” Pickett says. The clinic provides the following services:
- Evaluation to determine any immediate safety concerns.
- Brief intervention through temporary, on-site counseling and coping tips.
- Coordination of care with the child’s existing care team (pediatrician, school or other providers) to ensure everyone is aware of the child’s needs.
- Referrals to helpful resources following the child’s clinic visit, including follow-up care, if needed.