Characteristics and disposition of youth referred from schools for emergency psychiatric evaluation

Abstract

We aimed to describe the characteristics and disposition of youth referred from schools to the emergency department (ED) for psychiatric evaluations. Consecutive 12-month records of ED psychiatric consultations at a large urban hospital from 07.01.2009 to 06.30.2010 were retrospectively analyzed. School-initiated referrals were deemed inappropriate if youth were discharged from the ED without any recommended mental health follow-up. Of the 551 psychiatric ED evaluations, 243 (44.1%) were initiated by schools. Of all school referrals, only 19 (7.8%) children were psychiatrically hospitalized, 108 (44.4%) were discharged from the ED with a follow-up appointment; and 116 (47.7%) were discharged without arranged follow-up. Those with a chief complaint of "suicidality" (n = 109, 44.9%) were more likely to be discharged without arranged follow-up than youth with other presenting complaints (56.0 vs. 41.0%, p = 0.021). Altogether, only 37 (18.5%) of 200 school-referred youth with information were evaluated by a school nurse, social worker, or other professional before being sent to the ED. Students without in-school screening were significantly more frequently discharged without follow-up than students with in-school evaluations prior to the ED referral (51.5 vs. 27.0%, p = 0.0070; odds ratio = 2.87 (95% CI 1.30-6.31). Multivariate predictors of inappropriate school referrals of youth discharged without any outpatient follow-up were higher Children's Global Assessment Scale score (p < 0.0001), absent in-school evaluation (p = 0.0069), absent prior psychiatric history (p = 0.011) and absent current psychotropic medication treatment (p = 0.012) (r(2) = 0.264%, p < 0.0001). Altogether 44.1% of ED consultations were school referred, of which 47.7% were potentially inappropriate for the emergency setting. In-school screening, which occurred infrequently, reduced unnecessary evaluations by 52%.

Exploring School Nurse Interventions and Health and Education Outcomes: An Integrative Review

“…Seventeen studies focused on community and public health under the screenings/referral/follow-up ( n = 12), health education ( n = 2), surveillance ( n = 2) components, and under the overall umbrella of the community/public health principle ( n = 1). The majority of studies included screenings/referrals/follow-up on a variety of topics including anxiety (Allison, Nativio, Mitchell, Ren, & Yuhasz, 2014; Muggeo et al, 2017), body mass index (BMI; Lee & Kubik, 2015; Stalter, Chaudry, & Polivka, 2011), depression (Allison et al, 2014), somatic symptoms (e.g., headache, nausea, and heart racing) and general functioning (home, school, and peers; Muggeo et al, 2017), psychiatric evaluations and referrals to the emergency department (Grudnikoff, Taneli, & Correll, 2015), vision (Kemper, Helfrich, Talbot, & Patel, 2012), hearing (Sekhar et al, 2014), posture (Magee, Kenney, & Mullin, 2012), alcohol use (Lunstead, Weitzman, Kaye, & Levy, 2016), female athlete triad syndrome (Kroshus et al, 2015), acanthosis nigricans (Scott & Hall, 2012), and adolescent dating violence (Khubchandani et al, 2013).…”

“…Bergren (2016) also assessed school nurse data collection on the number of times students were dismissed from school early or sent back to class after health office visits. Types of screenings, referrals, and follow-up included screenings for depression and anxiety (Allison et al, 2014; Muggeo et al, 2017), physical symptoms and overall functioning related to anxiety (Muggeo et al, 2017), parental satisfaction with BMI notification letter (Lee & Kubik, 2015), number of students confirmed for postural curvature during screening (Magee et al, 2012), emergency department referrals for psychiatric evaluation (Grudnikoff et al, 2015), and the number of students who received follow-up eye exams after screening (Kemper et al, 2012). Studies examined whether sexual health and STI/HIV education by school nurses improved sex-related cognitive mediators (i.e., knowledge, efficacy, beliefs, and intentions; Borawski et al, 2015) and increased immunization compliance (Swallow & Roberts, 2016).…”

Emergency Department Use by Children and Youth with Mental Health Conditions: A Health Equity Agenda

“…ED utilization in the U.S. is increasing among children and youth who have public insurance or are uninsured and declining among those with private insurance (Kalb et al, 2019 ) ED referral 5. Increased ED utilization is driven largely by the referral of non-acute children and youth, with as many as 39% of referrals to EDs deemed inappropriate (Grudnikoff et al, 2015 ; Soto et al, 2009 ) 6. Of the nearly 50% of ED referrals of children and youth with mental health conditions that come from schools, most are not evaluated by a school nurse or professional prior to referral, and almost half of the referrals are likely to be deemed inappropriate (Grudnikoff et al, 2015 ) 7.…”

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

“…Psychomotor agitation is a frequent phenomenon and a clinically relevant condition in patients with psychiatric disorders, not only in urgent situations, but also in hospital or outpatient settings 5. Agitation with or without aggressiveness accounts for 2.6-52% of all psychiatric emergencies worldwide,6-12 and for 23.6-23.9% (∼24%) of psychiatric emergencies in Brazil 13,14…”