It is surprising to me that most people, even many pediatric nurses, are largely unaware that suicide is the second leading cause of death in children 15 to 19 years of age, and the third leading cause of death in children ages 10 to 14. As a society, we are doing a good job of promoting the use of seatbelts and helmets, but we are not doing nearly enough to adequately care for children with behavioral health needs.
Nationally, there is a critical shortage of mental health practitioners, especially for children. Families come to the ED because they don’t know where else to go, or they’ve been put on a waiting list and just can’t wait. But the wait doesn’t end in the ED, because staff struggle to place patients in appropriate settings. Children with traumatic brain injuries, significant co-morbid medical illnesses, developmental delays, or autism can often board in the ED for days because the psychiatric hospitals cannot accept them due to these exclusionary criteria.
This is a very challenging situation for nurses, physicians, social workers, and technicians who have little training in treating mental health issues. Additionally, boarding children in the ED for days does not provide them with the most appropriate psychiatric care.
Children’s Healthcare of Atlanta has a behavioral health consult service that covers the ED and the inpatient side of the hospital. As a member of that team, I respond to requests from colleagues who are managing children with mental health needs and from the physicians managing patients in psychiatric crisis on the ED. With the upward trend of behavioral health needs in the ED, we knew we had to make some changes.
Education and Resources
Our organization was particularly concerned about managing behavioral health patients who come to the ED after hours. We had a contracted mobile assessment team in the ED for overnight shifts, and while those clinicians provided good assessments in the moment, they were not regular staff. We wanted to provide the same consistent level of care around the clock.
The ED staff clinicians were providing excellent care for medical issues, but they felt unprepared to address the behavioral health needs of patients. Adapting a curriculum I had used in previous teaching positions, I developed an educational program for nurses that provides fundamental training in several key areas:
- Communicating effectively and therapeutically
- Understanding techniques to de-escalate crises
- Administering psychotropic medications safely
- Recognizing early warning signs for behavioral health diagnoses
In collaboration with, and with support from, the leadership team, I presented the program to 400 nursing staff members at five facilities, and across all shifts, during the first summer it was available.
Some of the key improvements from this focus on behavioral health are:
- Overcoming common misconceptions and stigma: Many nurses think about conditions like bipolar disorder or schizophrenia when we talk about mental health. In fact, those conditions are less common in pediatrics than in the adult population. Depression and anxiety are much more common in children. Recognizing early warning signs for depression and anxiety is especially important because most people who die by suicide have visited an ED or primary care setting in the prior 12 months.
- Putting essential nursing skills to use: Some clinicians believe there is a “fancy” way of talking to behavioral health patients. Therapeutic communication is actually at the core of what defines us as nurses. The skills nurses use in caring for a child who is highly anxious and distressed after a car wreck are no different than the skills needed to care for a child in the ED suffering a panic attack from generalized anxiety disorder. Reminding nurses of the skills they already have helps them have the confidence to manage behavioral health patients more effectively.
- Expanding the behavioral health team: At Children’s, social worker’s concentration has been on medical management, psychosocial support, resource connection, and child protection services. We developed a program and received funding to train and hire mental health-licensed clinical social workers to serve all shifts in the ED. Having greater numbers of staff available to assess behavioral health patients is resulting in more rapid placement in appropriate settings and improved communication between disciplines and facilities.
What Success Looks Like
Overall, the changes in our organization have offered improved continuity of care for patients and their families. Satisfaction surveys of patients, families, and staff have shown good results. In the future, we plan to collect more in-depth data and conduct follow-up calls with families to make sure patients have been able to access appropriate services.
We’ve also had success in spreading the effort across the organization. Once the ED began to focus on behavioral health, our staff began to discuss what else we could do to improve care for these patients. We’re working to find ways to collaborate with other agencies in our state that help youth with their behavioral health needs. I attend several different leadership meetings at our organization, and behavioral health is on the agenda of every one of them – that is a measure of success to me.
Yet what we can do in Georgia is only a piece of a national problem. Mental health problems in children are real, and they have many causes — biological, sociological, and environmental. This isn’t a family problem, a child problem, or a hospital problem. It’s a community problem. Ultimately, we need to address this issue together, and not assume any one person or group can solve it by themselves.
Erin Parker-Harlow, MS, APRN, PMSCNS-BC, is an advanced practice nurse focused on behavioral health in pediatrics.
You may also be interested in: