Emergency Department-Based Psychiatric Services for Children and Adolescents: An In-depth Investigation of Care in North Carolina

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PROJECT SUMMARY/ABSTRACT The prevalence of mental illness among children and adolescents in the U.S. is increasing, just as is use of the emergency department (ED) for mental health care. Pediatric patients (<18 years) who present to the ED with an acute psychiatric illness are distinctly different from those presenting to outpatient facilities. With suicide as a leading cause of death among this age group, psychiatric emergency services need to be strengthened as a primary resource for pediatric patients at risk. Unfortunately, EDs are ill-equipped to care for the growing number of pediatric patients with serious mental illness. Overcrowding has led to delays in care, longer ED visits, and decreased access to services for patients. Despite these adverse outcomes, research on evidence-based solutions to improve care have not laid a proper foundation to make meaningful change occur. Narrow contexts, single site investigations, restricted patient populations, and a lack of multi-intervention trials have factored into the limited impact of previous studies looking at potential solutions. In order to remedy this, a pragmatic, multi- faceted approach is needed to truly understand what processes of care are practical and effective at improving outcomes in real world EDs. Absent in the literature is a broad survey of what is currently being done in EDs and a discussion of the contexts in which these systems of care are successful. The proposed project seeks to lay the foundation for understanding these contextual factors by conducting an in-depth investigation of psychiatric ED care in a single state. The objective of this Kirschstein-NRSA F30 Fellowship is to identify real-world solutions to the growing burden of ED-based psychiatric care for children and adolescents. Aim 1 will describe the current structure and processes of pediatric psychiatric ED care through in-depth semi-structured interviews with different care providers at local hospital EDs. Aim 2 will evaluate how the changing demand for ED-based pediatric psychiatric care has impacted patient and hospital-level outcomes among hospitals within the University of North Carolina healthcare system using regression analysis. Aim 3 will further describe the current structure, processes, and outcomes of care through a broad survey of all North Carolina (NC) EDs in order to gather a wider breadth of information. Aims 1 and 2 will be used as one source of information to inform the survey in Aim 3. This proposal uses a mixed methods approach that will combine traditional quantitative analysis with qualitative coding and description of responses from Aims 1 and 3. Taken together, the results from these three aims will provide a foundation from which intervention-focused and implementation-driven research can be conducted to help create lasting change in how ED-based care is provided to children and adolescents. Through the proposed investigation, the outlined training plan, and the mentorship team described within this application, the trainee will grow as a future physician-scientist, strengthen her skills in both qualitative and quantitative methods, and position herself to further improve ED-based care through her future academic career.