Predictors of Repeated Visits to a Pediatric Emergency Department Crisis Intervention Program

Abstract

ObjectivesDespite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits.MethodsWe examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression.ResultsA total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances.ConclusionsRepeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.

Child and Adolescent Mental Health Repeat Visits to the Emergency Department: A Systematic Review

“…8,14,[17][18][19][20][21][22][23] Two additional studies also met inclusion criteria and were identified through references and our own work. 13,24 See Fig 1 for the flow diagram. Characteristics of included studies can be found in Table 1.…”

“…2,12 Effective management and appropriate detailed discharge plans, whether inpatient or outpatient, are important for reducing symptom worsening and recurrent use of the ED. 12 A substantial portion of ED MH visits made by children and adolescents (20%-45%) are return visits, 6,13 possibly suggesting that patients' needs are not being met after discharge, even though outpatient providers are often accessed. 14 Within overloaded EDs, repeat visits are a significant economic and resource burden.…”

Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers

“…Finally, outpatient BH service utilization patterns (e.g., availability of alternative outpatient services in a particular geographic area) may play a role in frequent pediatric ED visits. The findings of the systematic literature review (reported above) indicate that only a handful of studies (about five) examined the relationship between past or current behavioral services and repeat ED visits (Leon et al, 2017), and only one study examined treatment with psychotropic medication as a factor related to repeat ED visits, finding that children who used these medications were more likely to have repeat ED visits (Cloutier et al, 2017).…”

“…The first objective was to identify and describe the proportion of youth with a BH diagnosis who frequently visit the ED, and to describe their demographic, diagnostic, and ED arrival time characteristics. Since one past study found that medication-only BH treatment may be a factor in repeat ED visits, the second aim was to describe the types of psychotropic medications that were prescribed for these youth before and during the ED visit, as well as any changes in medication that may have occurred before and during the visit (Cloutier et al, 2017). The third objective was to analyze the demographic, clinical, and medication-related factors associated with high use of the ED for this population.…”

Evaluating mental health service use during and after emergency department visits in a multisite cohort of Canadian children and youth

“…Most children and youth presenting to the ED with a MH emergency are discharged home. 4,[14][15][16][17][18][19] Research suggests that 32% to 48% of youth do not receive discharge instructions, 11,20 and between 21% and 46% of patients return to the ED after their initial visit for additional crisis care, [21][22][23][24] which is not always due to increasing clinical acuity. 25 Furthermore, many discharged youth do not receive urgent outpatient MH care or physician-based outpatient care within 60 days following their ED visit.…”