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1.
J Acad Consult Liaison Psychiatry ; 64(6): 501-511, 2023.
Article in English | MEDLINE | ID: mdl-37301325

ABSTRACT

BACKGROUND: In 2021, several professional organizations declared a national state of emergency in child and adolescent mental health. Rising volume and acuity of pediatric mental health emergencies, coupled with reduced access to inpatient psychiatric care, has caused tremendous downstream pressures on EDs resulting in long lengths of stay, or "boarding", for youth awaiting psychiatric admission. Nationally, boarding times are highly heterogeneous, with medical / surgical patients experiencing much shorter boarding times compared to patients with primary mental health needs. There is little guidance on best practices in the care of the pediatric patient with significant mental health need "boarding" in the hospital setting. OBJECTIVE: There is a significant increase in the practice of "boarding" pediatric patients within emergency departments and inpatient medical floors while awaiting psychiatric admission. This study aims to provide consensus guidelines for the clinical care of this population. METHODS: Twenty-three panel participants of fifty-five initial participants (response rate 41.8%) committed to completing four successive rounds of questioning using Delphi consensus gathering methodology. Most (70%) were child psychiatrists and represented 17 health systems. RESULTS: Thirteen participants (56%) recommended maintaining boarded patients in the emergency department, while 78% indicated a temporal limit on boarding in the emergency department should prompt transfer to an inpatient pediatric floor. Of this group, 65% recommended a 24-hour threshold. Most participants (87%) recommended not caring for pediatric patients in the same space as adults. There was unanimous agreement that emergency medicine or hospitalists maintain primary ownership of patient care, while 91% agreed that child psychiatry should maintain a consultative role. Access to social work was deemed most important for staffing, followed by behavioral health nursing, psychiatrists, child life, rehabilitative services, and lastly, learning specialists. There was unanimous consensus that daily evaluation is necessary with 79% indicating vitals should be obtained every 12 hours. All agreed that if a child psychiatric provider is not available on-site, a virtual consultation is sufficient to provide mental health assessment. CONCLUSIONS: This study highlights findings of the first national consensus panel regarding the care of youth boarding in hospital-based settings and provides promising beginnings to standardizing clinical practice while informing future research efforts.


Subject(s)
Mental Disorders , Mental Health , Adult , Adolescent , Humans , Child , Length of Stay , Mental Disorders/epidemiology , Mental Disorders/therapy , Hospitalization , Emergency Service, Hospital
2.
J Intensive Care Med ; 34(5): 383-390, 2019 May.
Article in English | MEDLINE | ID: mdl-28859578

ABSTRACT

OBJECTIVES:: Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. METHODS:: This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. RESULTS:: A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). CONCLUSIONS:: Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.


Subject(s)
Delirium/prevention & control , Intensive Care Units, Pediatric/standards , Noise/prevention & control , Patient Care Bundles/instrumentation , Patients' Rooms/standards , Child , Delirium/etiology , Female , Humans , Male , Noise/adverse effects , Pilot Projects , Quality Improvement
3.
Curr Psychiatry Rep ; 20(11): 104, 2018 09 24.
Article in English | MEDLINE | ID: mdl-30246221

ABSTRACT

PURPOSE OF REVIEW: Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use. RECENT FINDINGS: Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.


Subject(s)
Bone Density/drug effects , Psychotropic Drugs/pharmacology , Psychotropic Drugs/therapeutic use , Adolescent , Anticonvulsants/pharmacology , Anticonvulsants/therapeutic use , Antidepressive Agents/pharmacology , Antidepressive Agents/therapeutic use , Antimanic Agents/pharmacology , Antimanic Agents/therapeutic use , Antipsychotic Agents/pharmacology , Antipsychotic Agents/therapeutic use , Benzodiazepines/pharmacology , Benzodiazepines/therapeutic use , Central Nervous System Stimulants/pharmacology , Central Nervous System Stimulants/therapeutic use , Child , Humans , Polypharmacy
4.
Child Adolesc Psychiatr Clin N Am ; 26(3): 597-609, 2017 07.
Article in English | MEDLINE | ID: mdl-28577612

ABSTRACT

This article reviews mental health access issues relevant to preschool children and data on this population obtained through the Michigan Child Collaborative Care Program (MC3). The MC3 program provides telephonic consultation to primary care physicians (PCPs) in 40 counties in Michigan and video telepsychiatric consultation to patients and families. Attention-deficit/hyperactivity disorder and disruptive behavioral disorders are frequent initial presenting diagnoses, but autism spectrum disorders, parent-child relational issues, trauma, and posttraumatic stress disorder should also be considered. Collaborative care programs provide promising ways to promote access to child psychiatric services when these services are distant to local PCP offices.


Subject(s)
Child Health Services/organization & administration , Intersectoral Collaboration , Mental Disorders/diagnosis , Mental Disorders/therapy , Mental Health Services/organization & administration , Primary Health Care/organization & administration , Telemedicine/organization & administration , Child, Preschool , Humans , Mental Disorders/drug therapy
5.
Pediatrics ; 139(1)2017 01.
Article in English | MEDLINE | ID: mdl-27940505

ABSTRACT

A 14-year-old previously healthy female was transferred from a local emergency department after being found unresponsive at home. Parental questioning revealed she had fever and pharyngitis 2 weeks before presentation. Past mental health history was negative, including concern for past or present suicidal ideation/attempts, suspected substance use, or toxic ingestion. In the emergency department, she was orotracheally intubated due to a Glasgow Coma Scale of 3. She was hemodynamically stable and euglycemic. Electrocardiogram showed sinus tachycardia. She underwent a noncontrast head computed tomography that was normal and subsequently underwent a lumbar puncture. She had a seizure and was given a loading dose of diazepam and fosphenytoin that led to cessation of extremity movements. She was subsequently transferred to the PICU for additional evaluation. Initial examination without sedation or analgesia demonstrated dilated and minimally responsive pupils, intermittent decorticate posturing, and bilateral lower extremity rigidity and clonus, consistent with a Glasgow Coma Scale of 5. Serum studies were unremarkable with the exception of mild leukocytosis. Chest radiograph only showed atelectasis. She was empirically started on antibiotics to cover for meningitis pending final cerebral spinal fluid test results. The pediatric neurology team was consulted for EEG monitoring, and the patient was eventually sent for computed tomography angiogram and magnetic resonance angiogram/venogram. We will review diagnostic evaluation and management of an adolescent patient with acute encephalopathy with decorticate posturing of unclear etiology.


Subject(s)
Acute Febrile Encephalopathy/chemically induced , Acute Febrile Encephalopathy/etiology , Acute Febrile Encephalopathy/therapy , Amitriptyline/analogs & derivatives , Bupropion/toxicity , Decerebrate State/chemically induced , Decerebrate State/etiology , Serotonin Syndrome/diagnosis , Suicide, Attempted , Venlafaxine Hydrochloride/toxicity , Acute Febrile Encephalopathy/diagnostic imaging , Adolescent , Amitriptyline/toxicity , Brain/diagnostic imaging , Decerebrate State/diagnostic imaging , Diagnosis, Differential , Emergency Service, Hospital , Female , Glasgow Coma Scale , Humans , Intensive Care Units, Pediatric , Interdisciplinary Communication , Intersectoral Collaboration , Magnetic Resonance Angiography , Magnetic Resonance Imaging , Self Medication , Suicide, Attempted/prevention & control , Tomography, X-Ray Computed
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