key: cord-0849676-0w4bbfzu
authors: Bowden, Cadence F.; Worsley, Diana; Doupnik, Stephanie K.
title: Mental Health and COVID-19 in Pediatric Emergency Departments: Perspectives from Directors
date: 2022-04-19
journal: J Adolesc Health
DOI: 10.1016/j.jadohealth.2022.03.019
sha: 02d3d6077417e9737942368b1bbb766490b01d3b
doc_id: 849676
cord_uid: 0w4bbfzu

PURPOSE: Understand Pediatric Emergency Department (PED) directors’ perspectives on the COVID-19 pandemic’s effect on PED visits for mental health concerns. METHODS: Semi-structured phone interviews were conducted with a national convenience sample of PED directors. Interviews were recorded, transcribed verbatim, and analyzed using rapid content analysis. RESULTS: 21 PED directors from 18 states were interviewed. Directors perceived an increased volume of mental health visits and higher patient acuity. Some PEDs innovatively adapted services but were also met with new barriers in providing care due to increased use of PPE and required COVID-19 testing. Transfer to inpatient psychiatric units was more complicated due to reduced overall bed capacity and the need for a negative COVID test. CONCLUSIONS: The COVID-19 pandemic strained an already fragile pediatric emergency mental health system. Building infrastructure for adaptations and mental health service reserve capacity could help ensure proper care for pediatric patients with mental health crises during future public health emergencies.

Pediatric emergency department (PED) visits for suicidal ideation or attempt have been 25 rising for years, 1 and the COVID-19 pandemic has added additional strain on children's mental 26 health (MH). 2 We sought to understand PED directors' perspectives on the COVID-19 27 pandemic's effect on PED visits for MH concerns. convenience sample for this qualitative study included survey respondents who indicated they 33 would be interested in completing an interview. 34

The interviews focused on PED MH practices, with emphasis on implementation of 35 practices and organizational culture and resources. The interview guide was iteratively refined 36 based on preliminary interviews to include questions about changes in PED practices during the 37 COVID-19 pandemic. Interviews were audio-recorded and transcribed verbatim. As outlined in 38 detail in Supplement 1, we used a rapid analysis approach, 3,4 to analyze domains related to 39 COVID-19 and MH. Rapid qualitative analysis is considered a particularly advantageous 40 approach for studying time-sensitive phenomena and when actionable results are needed, 5 both 41 of which apply to the COVID-19 and accompanying MH pandemic. In our study, the three pre-42 determined analytic domains focused on how the COVID-19 pandemic affected (1) patients' 43 mental health emergency presentations (2) provision of mental health services; and (3) discharge 44 dispositions. These domains were selected based on data from preliminary interviews and 45 research team members' clinical experience. Analysis within and across domains was conducted 46 by two Masters-level analysts experienced in qualitative research. The team met regularly to 47 discuss results and resolve discrepancies in coding. The IRB determined that this minimal risk 48 study was exempt from review. Informed consent was obtained from all subjects. 49 50

Of the 35 PED directors who indicated they were interested in an interview, 11 were 52 unable to be reached in the study timeframe, 3 declined to participate due to scheduling, and 21 53 enrolled and completed an interview between December 2020 and February 2021. PED director 54 characteristics are provided in Table 1 . Below we present our three domains of analysis. Table 2  55 includes exemplary quotes to support each domain. 56 57

Most PED directors noted that their EDs saw an initial decrease in the volume of MH 59 presentations at the beginning of the pandemic, followed by a prolonged increase after the 60 pandemic had continued for several months. Many said that although overall PED visit volumes 61 had decreased, MH-related PED presentations had increased. Respondents also noted that the 62 severity and acuity of patients' MH symptoms seemed to have increased so that MH visits made 63 up a greater proportion of overall PED volumes. Directors discussed that the severity and acuity 64 of patients' MH symptoms seemed to have increased since the onset of the pandemic. Some 65 directors reported their staff felt that they lacked the education and experience to manage the 66 increasing volumes and acuity of MH cases, and that the COVID-related precautions such as 67 donning and doffing personal protective equipment (PPE), added to staff frustration. 68 69 J o u r n a l P r e -p r o o f

When asked about telehealth use for MH concerns, participants ranged from reporting no 71 telehealth use to saying telehealth increased dramatically. Telehealth consults for social work 72 and psychiatric evaluations were most common. The availability of telehealth was seen by some 73 as a facilitator to better care for a growing MH patient population, whereas other respondents 74 said that telehealth was not ideal for mental healthcare or the PED setting. Further impeding 75 ideal MH care in the PED was the use of PPE, which several directors reported hindered staff's 76 ability to build rapport with MH patients. 77

Another change in service provision due to the pandemic was the need to perform a 78 COVID-19 test prior to initiating MH services. In some cases, patients were left waiting without 79 evaluations or services for many hours while awaiting COVID-19 test results. Our study can be interpreted in the context of limitations. First, the study was designed to 117 focus on MH services provision in PEDs (not specifically on the effects of COVID-19). 118 Therefore, the conceptual models used to develop the interview guide did not focus on pandemic 119 preparedness, and other COVID-19 related changes to PED care were outside the scope of our 120 interviews. However, the structured nature of the interviews lent the data to rapid analysis based 121 upon pre-determined domains related to COVID-19. Second, while our sample was largely 122 urban, academic PEDs, it was geographically diverse and evenly split between freestanding 123

PEDs and those nested within general adult hospitals. Still, results may not be generalizable 124 beyond the PEDs included in our interviews. 125

Our study's main findings showed that PED staff experienced stress related to the 126 increasing volume and acuity of patients seeking MH crisis care; that requirements to use PPE 127 and have COVID-testing results were barriers to high-quality patient care; and that MH services 128 capacity was inadequate to meet patients' MH needs. Increased use of telehealth was an 129 innovation spurred by the COVID-19 pandemic, and study participants were mixed on whether 130 telehealth care was advantageous for patients seeking MH care in the PED. 131 J o u r n a l P r e -p r o o f The number of patients that did not have preexisting psychiatric illness increased, or the patients that didn't have preexisting conditions, but were coming in with new suicidality increased, as well. So, it [the pandemic] had a profound effect. The numbers are higher, and the length of stays are longer." PED Director 7 "I mean, the -it seems like the acuity's higher. All the resources are exhausted. All the resiliency is exhausted by the pandemic." PED Director 11 "I think our psych volume has almost doubled. So, we're very, very busy with psych patients and obviously it's a stretched -it's not a resource-rich specialty anywhere, let alone where I'm practicing. And I think there's a big strain on the system right now." PED Director 16 Effect of COVID-19 on mental health service provision "So I think one thing that's gotten in the way is if we had a lot psych patients waiting to be seen, there would just be a lot of people in this hallway waiting. But with COVID, it's not ideal to have that many people together. So that's been a challenge in that when there are more patients than spots, finding additional places where they can be safely, without being an infectious control risk is challenging." PED Director 9

"We have plenty of PPE. It just takes us longer to see patients, every patient, because we are donning and offing PPE for every single patient." PED Director 19 Effect of COVID-19 on mental health discharge dispositions "The number of psychiatric beds either has not increased, and in many occasions, has actually decreased. And due to the COVID constraints, many hospitals where they used to have double beds or shared rooms, they just became a private room, so that also decreased the number of patients who could be admitted." PED Director 21 "I can say that the inpatient psych facilities have been kind of strict with the COVID testing. They want us to actually repeat a test if the patient's there more than 72 hours in our ED, and some of them actually want a PCR, they don't want just antigen testing." PED Director 4 "So certainly the pandemic has impacted what we do as far as if they need to be admitted and there have been COVID outbreaks at the psychiatric hospital on the in-patient ward, so that did get closed down. COVID has impacted the resources that are available, we've certainly felt that." PED Director 2 Abbreviations: COVID -Coronavirus Disease; ED -Emergency Department; PCR -Polymerase Chain Reaction; PED -Pediatric Emergency Department; PPEpersonal protective equipment

Hospitalization for Suicide Ideation or Attempt

Children and Teens Struggling with Mental Health During