Improving Psychiatric Access for Students in Crisis: An Alternative to the Emergency Department

From January 1 to June 30 of 2014, a total of 72 students were referred to the UES, of which 70 were evaluated; two students were referred out due to lack of active crisis. (A table showing students’ demographic characteristics is provided as an online supplement.) Only one student seen during this period required referral to a higher level of care, indicating that school staff were largely able to appropriately triage and refer students to the UES and that urgent outpatient evaluation was, in fact, the appropriate level of care. At the same time, having emergency psychiatry services on site helped to ensure that a higher level of care was available if needed. Referrals to the UES largely mirrored school referrals to the pediatric ED, with the largest proportion referred for evaluation of suicidal ideation (N=26, 36%) and self-injurious behavior (N=18, 25%), followed by disruptive behavior (N=11, 15%). Of note, this last grouping refers to students with disruptive behaviors in class but who were not acutely agitated at the time of assessment and could cooperate with the evaluation process. Fifty-eight percent of referred students were female (N=42), and 42% were male (N=30), with the largest proportion of referrals coming from middle school (N=33, 46%), followed by high school (N=23, 32%) and elementary school (N=16, 22%). The high incidence of middle school referrals may speak to the challenges associated with identifying and effectively managing emerging behavioral health issues, particularly depression and anxiety, in this population. Although a majority (N=57, 79%) of students seen in the UES had no prior history of mental health treatment, one striking finding was that 21% (N=15) of those referred already had established outpatient services. It is unclear whether they had first attempted to reach their own provider and were unable or whether they came directly to the UES. Either way, this finding speaks to the potential to improve crisis management and cross-system collaboration between outpatient mental health providers and schools.

A total of 423 pediatric psychiatry visits presented to the pediatric ED in January–June 2013, compared with 313 visits in January–June 2014 during the UES pilot. School referrals represented 44% (N=185) of the total volume of psychiatry visits in 2013, compared with 34% (N=107) in 2014, an absolute decrease of 78 visits. This decrease corresponds approximately to the 71 visits seen in the UES and suggests successful diversion of these visits from the pediatric ED, as was factored into the initial design and staffing of the model. A similar decrease was not observed among other subgroups of ED referral sources, such as home or the pediatrician’s office. The change in the volume of school referrals to the ED was most pronounced during UES hours of operation, dropping from 80 to 45 pre- and postpilot, a decrease of 44%. Simultaneously, the admission rate of school referrals to the ED during the day shift increased from 4% (N=3) in 2013 to 11% (N=5) in 2014, suggesting an increase in the proportion of clinically appropriate ED referrals, with subacute referrals being diverted to the UES. A similar shift was not observed during evenings and weekends.

Although not formally measured, feedback from schools during this pilot was uniformly positive. Unlike the ED, the UES clearly identified a consistent point of contact for schools making a referral. This is of particular value to schools that are highly motivated to obtain assistance in managing crises but typically face a paucity of collaborators from the mental health system. Often, simply reaching out to the referring school to discuss a student had a significant “warming” effect on improving cross-system relationships and driving additional referrals. Schools not included in the initial information session were informed of the UES when they sent a student to the ED for consultation. Several schools also began to make requests for additional staff training, highlighting the opportunity to build on the foundation of accessible crisis services to develop broader “upstream” interventions.

With respect to patient engagement, it has been noted that the ED can be the first point of mental health treatment for many children (9). Unfortunately, given the limitations previously cited, it can, at times, magnify stigma and decrease the likelihood of follow-up. Relocating these evaluations to a specialized ambulatory service sets the stage for a different experience, providing a therapeutic environment that is more conducive to engagement. Assisting families with securing follow-up and bridging care until they are connected similarly adds value that is often missing from an ED visit.

The short duration of the pilot study and the lack of widespread advertising of the UES meant that many schools still sent subacute referrals to the ED, particularly those schools that were not part of the initial outreach session. Conversely, some youths who were appropriately referred to the UES mistakenly presented to the ED, which, because of Emergency Medical Treatment and Labor Act regulations, was unable to triage patients to the UES and still had to conduct an ED evaluation and call for psychiatric consultation. The service impact was also greatly limited by the hours of operation, which were restricted to school hours.