Children with mental health issues presenting to EDs

Children with acute mental health problems are increasingly presenting to emergency departments because they cannot access an appropriate bed, leading to costly hospital admissions.

A study that looked at all emergency mental health (MH) admissions at one Dublin children’s hospital in 2016 found the cost per child was €12,684, based on a six-day stay. There were 105 emergency MH admissions during this time, at an estimated cost to the hospital of €1.3m.

The authors of ‘Hidden Costs in Paediatric Psychiatry Consultation Liaison Services’ (PCLS, also known as hospital-based mental health services), published in the Irish Medical Journal, said admissions are being driven up by a lack of capacity in Child and Adolescent Mental Health Services (CAMHS), and the lack of out-of-hours services.

The upshot is “demand outweighs availability, and immediate access remains problematic, the default often being a paediatric admission”.

This runs contrary to the aim of the PCLS, which were designed to provide cost-effective interventions for patients with both physical and psychiatric conditions.

PCLS reviewed 151 in-patients for this study, average age 13. The majority were already known to child and adolescent MH services.

The authors, Claire Kehoe and Fiona McNicholas, say these patients “might be better managed by CAMHS, who have an existing relationship with them, and who have more comprehensive multi-disciplinary teams”.

They point out that the PCLS staffing in the hospital “is already well below recommended levels” so that the additional emergency-based work has “significant repercussions” for the availability of PCLS to respond to other referrals.

Most of the children in this study, 120, presented directly to the ED, mainly after hours (83). The majority had mood/anxiety disorders (91). Deliberate self-harm was present in almost half (40%), as was suicidal ideation (48%).

Seventeen children had eating disorders. The total cost of treating the eating disorders group over 12 months was €1.8m.

The authors said given the high costs associated with hospital admission, the inappropriate use of acute hospital beds “is of relevance to policymakers, clinicians and indirectly to patients”.

They say ensuring dedicated MH beds are available for under 16s “continues to be problematic, therefore creating a vulnerable group with immediate access only to hospital EDs”.

The authors said the number, range and mix of beds appropriate for future demand need to be carefully considered.

“This is especially pertinent with plans for the development of the National Children’s Hospital 20-bed in-patient CAMHS unit and eight-bed Eating Disorder unit, to ensure that this caters appropriately for young children who are currently silently accessing expensive paediatric hospital beds.”

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