Children taken to the emergency room for mental health concerns are more likely to be stuck there for extended stays than they were a decade ago, according to new research. Hispanic children are almost three times more likely than white children to experience these delays in care.
“Every minute, every hour, every day a kid with mental health care [needs] spends in the ED is a delay in the care that they actually need,” said Katherine Nash, author of the study, published Monday in the journal Pediatrics.
Nash and her team at Yale University analyzed national survey data from 2005-2015, focusing on patient length of stay in the emergency room. They found that rates of visits that lasted more than six hours for pediatric mental health concerns increased from around 16% to almost a full quarter of visits. Stays longer than 12 hours increased from 5% to almost 13%.
While researchers are not sure what is causing the delays, they believe they are a sign of worsening access to adequate pediatric mental health care.
Emergency departments aren’t designed for mental health emergencies, and in most hospitals, they aren’t designed for children, either. They can be loud, chaotic, and a traumatic experience, said Nash. Still, they often serve as a point of entry to more specialized care for children experiencing a mental health issue. The number of adolescents experiencing mental health crises has increased over the years, with a particularly intense volume during the pandemic.
Through this surge, the emergency room has become more of a bottleneck as kids are forced to wait for understaffed pediatric departments to send a consulting physician, or for the adults to find an outside facility that is equipped to handle a child’s unique comorbidities or risk factors. Only 16% of children who came to the emergency room for a mental health visit ever saw a mental health provider, according to the study.
When children are identified as high risk of causing harm to themselves or someone else, they cannot safely return home. These children may need to wait in the emergency room for hours or even days until they can see a specialist or be transferred to an appropriate psychiatric facility.
“We would never let a child with diabetes wait for a week to see an endocrinologist and start their insulin,” said Lois Lee, a physician at Boston Children’s Hospital not involved in the study. “However, we are letting these children wait for a week to get the care they need.”
Children exhibiting violent or dangerous behavior need experienced providers who can keep them safe and provide medication when appropriate. Lee says that she’s seen children wait for mental health care in the emergency room for days at a time.
In general emergency departments, children waiting for mental health treatment also delay care for other emergency patients who need a bed.
“Emergency department utilization is a precious resource,” said Polina Krass, a physician at Children’s Hospital of Philadelphia who co-authored a commentary on the study.
For non-white Hispanic children, the barriers to access seem to be even higher, with three times the odds of an extended stay. This disparity was not present for other racial groups, which leads experts to question whether language barriers contribute to the delays in care.
“The implication of this work is that there are situations in which we can be providing better quality transitions to definitive care,” said Krass.
At least part of the solution to these delays of care may lie outside of the emergency room, Krass said. More options are needed for kids experiencing mental illness too acute to wait weeks to see a therapist, but also not so urgent that they need to be in the hospital for the night. The most recent pandemic stimulus package passed by Congress did allot funds for states to develop their own crisis response systems as a potential alternative for anyone calling 911. This is in addition to the new national three-digit number, 988, that connects to crisis centers for mental health emergencies that was signed into law last year.
More descriptive research is needed on causes behind the extended emergency room stays for children in mental health crisis in order to create more solutions, Krass said.
“Given that it is an administrative database, you don’t really get into the nitty gritty details of the true experience of these children and teenagers and families,” said Lee.
Nash hopes to continue research on length of stay for pediatric patients and to take a closer look at interventions that have yet to be tested in emergency departments.
“A mentor once told me to study what makes you angry,” Nash said. “And this is very much that.”