Behavioral Health ED Visit: Expectations and Limitations

 

CME CREDIT NOW AVAILABLE-1.0 AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!

By: Kristin Weinschenk, MD and Michael Lowley, MD

Kristin.Weinschenk@choa.org

The primary goal of the psychiatric evaluation in an ED setting is to assess the safety of the individual, and to connect them with resources at the appropriate level of care. This begins at triage with a screening tool called the ASQ (Ask Suicide-Screening Questions to Everyone in Medical Setting), a five-item questionnaire which flags patients for risk of recent or current thoughts of self-harm. A positive screen will then trigger referral for amore detailed evaluation by either the psychiatric social worker in the ED, or by a member of the Psychiatry Consult Liaison service. The MH professional will conduct a psychosocial assessment, and complete a more detailed suicide risk assessment tool called the BSSA. Once level of risk is established, the treatment plan will reflect the need for appropriate safety and monitoring, whether at an inpatient psychiatric hospital or in a less restrictive care setting.

 

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Presently, we are witnessing not only an increase in volume of patients presenting for evaluation (see figure above) but an increase in acuity, with greater numbers of patients requiring transfer for inpatient psychiatric hospitalization (see figure below).

 

CHOA does not have an inpatient psychiatric unit, therefore all patients requiring inpatient psychiatric services are referred to an outside hospital. Each facility has their own system for reviewing referrals. The admission process varies considerably based on a patient’s presenting symptoms, insurance provider, and age. It can be challenging to find placement for patients under 12 years of age, and for patients with intellectual disabilities or diagnosis of autism.

For those patients who are deemed safe to return home, we utilize resources available through the patients’ insurance, or those offered by the state. The state-run Georgia Crisis and Access Line (GCAL 1-800-715-4225) connects families to the appropriate Community Service Board (CSB, low-cost outpatient providers available in every county). Parents are asked to keep close watch of patients discharged from the emergency room, and to eliminate the minor’s access to medications, firearms, and other weapons. Parents and patients also work collaboratively with the ED MH provider to develop a personal safety plan to enact if thoughts of suicide develop.

Parents may ask if patients can be prescribed a medication for their mood, and return home from the ED. While in some cases this can be safe and appropriate, it is not typically recommended to start an antidepressant without first establishing consistent outpatient care. This is due to the need for close follow up during the initiation phase of antidepressants, as each carries risk of a rare but serious side effect of increased thoughts of suicide in those under 25 years of age.

In spite of the resource and time pressures associated with delivering mental health assessments in the ED setting, it is important to reflect on the significant impact we can make on our patients lives. A positive initial interaction with a mental health professional has the power to calm a crisis, form a positive opinion of mental health treatment for children and their families, and increase the likelihood of follow up.  For primary care provider CHOA also has a behavioral health advice line the number to contact is 404-785-DOCS (3627)

 

References:

1 Georgia Department of Public Health, Office of Health Indicators for Planning (OHIP). Retrieved from:

https://oasis.state.ga.us/

2. May 10, 2018: Georgia Bureau of Investigation News Release. Retrieved from:

https://gbi.georgia.gov/press-releases/2018-05-10/gbi-child-fatality-review-unit-releases-youth-suicide-data-2018

  

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