Thanks to everyone for joining the #CochraneChild Twitter journal club on May 27th, 2015 with TREKK's own Dr. Terry Klassen and Dr. Amanda Newton. The archived discussion is at: http://bit.ly/CrisisJC
What: Twitter journal club on crisis interventions for pediatric mental health in the emergency department
When: Wednesday, May 27th, 1:00pm PT Vancouver | 2:00pm MT Edmonton & Calgary | 3:00pm CT Winnipeg | 4:00pm ET Toronto
Where: Follow #CochraneChild on Twitter and join in the discussion by including #CochraneChild in all your posts. See these tips for participating in a Twitter chat.
Questions we will be addressing:
1. How often do Emergency Department (ED) clinicians see a patient for mental health care? Have visit trends changed over time?
2. Based on the 2010 review, what interventions have been tested for pediatric crisis care in the ED?
3. The studies included in the review were all observational studies. What are the challenges with this? Would other study designs have worked in this context?
4. What care do children and youth currently receiving in EDs for mental health emergencies?
5. Have new studies of ED-based crisis care been published since the 2010 review highlighted today?
Dr Terry Klassen Bio-sketch:
Dr. Klassen graduated from the Faculty of Medicine, University of Manitoba in 1982 and completed his Pediatric Residency training at the University of Manitoba in 1986. He completed M.Sc. in Epidemiology at McMaster University in 1994. He has served as CEO and Scientific Director for the Children’s Hospital Research Institute of Manitoba and Associate Dean, Academic in the College of Medicine, Faculty of Health Sciences at the University of Manitoba and Director of the George and Fay Yee Center for Healthcare Innovation since returning to Manitoba in September, 2010. Since the commencement of his new role as Head of the Department of Pediatrics, he has stepped down from the Associate Dean, Academic position but continues to serve both the Children’s Hospital Research Institute of Manitoba and CHI roles.
From 1999 to 2009 Dr. Klassen was Chair of the Department of Pediatrics, University of Alberta; Director of the Alberta Research Centre for Health Evidence and Director of the Evidence-based Practice Center at the University of Alberta. He is a clinician scientist focused on Pediatric Emergency Medicine, and has been active in Pediatric Emergency Research Canada collaborating on a national research program involving randomized controlled trials, systematic reviews and knowledge translation. He has a consistent record of national and international peer reviewed funding, along with a publication record that has included many articles in the highest impact medical journals.
In 2009, Dr. Klassen co-founded StaR Child Health, an international group aimed at improving the design, conduct and publication of randomized controlled trials in children. In recognition for his lifetime contributions, he was elected into the Institute of Medicine in 2010 in the foreign associate category. He is also a Fellow in the Canadian Academy of Health Sciences. Dr. Klassen’s research has had a large impact on the practice of Pediatric Emergency Medicine, which was recognized when he received a 2011 Canadian Institutes of Health Research – Canadian Medical Association Journal Top Achievements in Health Research Award. In 2011 he was also awarded the Networks of Centres of Excellence (NCE) grant, entitled TRanslating Emergency Knowledge for Kids (TREKK). In 2012 Dr. Klassen was appointed to the Governing Council of the Canadian Institutes of Health Research.
Dr. Amanda Newton Bio-sketch:
Dr. Newton is an Associate Professor in the Department of Pediatrics at the University of Alberta (Edmonton, Alberta, Canada) and clinician scientist affiliated with the Stollery Children’s Hospital in Edmonton. Her research aims to improve mental health care and outcomes for children and youth who are acutely mentally ill.
From team: News and Events
May 25, 2015 - This week's post is also available from the Cochrane Child Health blog.
Children’s Mental Health by the Numbers
Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses . Fewer than 20% of them receive appropriate treatment . And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% .
Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.
While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care.
Emergency Department-Based Management Interventions for Mental Health Presentations
A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints . There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.
The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.
Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.
Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.
Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.
Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.
Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”
Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.
1. Mental Health Commission of Canada. (2013). School-based mental health and substance abuse project.
2. Mental Health Commission of Canada. (2015). Topics: Child and Youth.
3. Canadian Institute for Health Information. (2015). Care for Children and Youth with Mental Disorders.
4. Hamm, M. P., Osmond, M., Curran, J., Scott, S., Ali, S., Hartling, L., . . . Newton, A. S. (2010). A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research. Pediatr Emerg Care, 26(12), 952-962. doi: 10.1097/PEC.0b013e3181fe9211
From team: News and Events
TREKK has had a very eventful first year --- challenges but also some real highlights. I don’t think any of us envisaged how difficult it would be to go into each of our TREKK emergency departments (ED) with iPads to determine the knowledge needs of our health care providers and consumers. But we have persevered, and whether it was ethics or operational approval, funding agreements or other obstacles we have made great strides with over 1100 responses from providers and 350 from consumers. The prioritization committee is already starting to examine these responses for patterns and to get a sense of how best to organize the next phase of getting knowledge tools in these EDs to improve care.
Part of our success of the first year is directly tied into the quality of our team that we have been building. Having TREKK/PERC coordinators do the front end work of creating the relationship with these EDs guided by the needs assessment team in Edmonton. Our nodal leaders, PERC site leads and steering committee have provided great advice and wisdom. Our central administrative team has now been recruited and is first rate – with Lisa Knisley as knowledge broker/network manager and Christa Kruck as the research coordinator. Of course, most importantly are the TREKK sites that have generously opened their doors and allowed us to get to know them better and helped champion this important project.
We are now actively collating the refined knowledge tools that are out there – be they systematic reviews, clinical practice guidelines, pathways or preprinted order forms we will try to find them if they are of sufficient quality and relevant to the care of children in a general ED. We will look at the results of the needs survey to get a sense of how best to provide them to the TREKK sites. Do people still like paper or is the internet the way to go? Maybe everyone has a smartphone and that is the preferred method. We are open and flexible.
Telling the TREKK story, although still in its early chapters, is always very exciting for me. To have 12 PERC sites and 35 TREKK sites come together as a network in such a short time is amazing. We need to work further on strengthening and developing this network. It has been exciting to present TREKK at CAEP in Niagara Falls and CCYHC in Vancouver in 2012. On March 25, I have been invited to present TREKK at Evidence Live 2013 at Oxford University (http://www.evidencelive.org/) and they are already blogging about it (http://doc2doc.bmj.com/forums/bmj_evidence-2011_trekk-evidence-based-medicine-emergency-paediatrics).
I think what most excites me about TREKK is when I reflect on the children and their families that visit our general EDs. The possibility that we can have an impact and improve some of their outcomes is truly motivating. Together we can do so.
From team: News and Events