An Initiative to Improve Efficiency of Emergency Department Adolescent Behavioral Health Visits

Pediatric mental illnesses are quite prevalent in the United States and worldwide. Prevalence has been increasing, and it is estimated that 13% to 20% of US children have a mental illness that costs an estimated $247 billion per year and affects children's social, emotional, and cognitive development (Perou et al. MMWR Suppl. 2013;62:1-35). Pediatric behavioral health visits to the emergency department (ED) have been on an exponential rise constituting 5% to 7% of ED visits (Kalb et al. Pediatrics. 2019;143(4):e20182192). This requires pediatric emergency physicians to frequently manage pediatric mental health illnesses and interact with pediatric psychiatrists to create an integrated system.There is no universally accepted protocol for medical clearance of psychiatric patients (Corl et al. Med Health R I. 2008 91(11):339-341). Our medical clearance protocol comprised complete blood counts, complete metabolic panel, thyroid panel, urine toxicology screen, blood alcohol, urine human chorionic gonadotropin for females, and electrocardiogram for patients 16 years and older. These tests are obtained and have to result in pediatric ED before admission to the adolescent psychiatry unit, therefore occupying space and contributing to pediatric ED overcrowding. In an attempt to decrease our length of stay (LOS), we worked with multiple stakeholders to modify this protocol.Based on results of the data extrapolated from adult psychiatry studies (Olshaker et al. Acad Emerg Med. 1997;4(2), 124-128; Parmar et al. West J Emerg Med. 2012;13(5), 388-393; Janiak and Atteberry. J Emerg Med. 2012;43(5), 866-870). The medical clearance process was adjusted, and laboratory tests, electrocardiogram, and other ancillary studies were waived. The new protocol indicates testing based on a detailed history, physical examination, and clinical judgment. The new medical clearance protocol was initiated in December 2018. The median ED LOS for patients seen in the ED and admitted to our inpatient unit from January to November 2018 was 290 minutes in comparison with median LOS for December 2018 to December 2019 period, which was 204 minutes, showing a median reduction of 86 minutes with no adverse outcomes.The median number of encounters requiring admission in both these periods was comparable. A downstream effect of this process was also cost savings. The estimated cost savings ranged from $37.45 to $47.5 per patient, not including labor and other indirect costs. The medical clearance process is a daunting process for both patients and their families and emerging data questioning its use. Goal-directed medical clearance may be an efficient and cost-saving medical clearance for patients requiring emergent psychiatric evaluation.