NUBE 2025

Background: There have been significant increases in both pediatric visits for mental health to the emergency department, and the prevalence of autism spectrum disorder (ASD). However, there is a relative dearth of information about patients with autism spectrum disorder (ASD) or intellectual disability (ID) who seek emergency psychiatric care. There are unique challenges associated with this patient population in the emergency setting. Given this backdrop, this retrospective study explored clinical, demographic, and disposition-related information about this patient population over a 10-year period.

Methods: This study included individuals with ASD or ID (n =1461) and had presented to a psychiatric emergency department between 2012-2021. Data were extracted using a structured chart review methodology, and included demographic, clinical and visit information. Demographic data included: race/ethnicity, age, and primary insurance type. Clinical data included: Co-occurring disorders, reason for visit, prior treatment history, abuse history, and current medications. Visit data included: Medications given, restraints information, and disposition.

Results: Sample was predominantly White (77.21%), adolescent (mean age ± SD = 15.5 ± 4.3) and male (72.76%). There was an abuse history in a significant % of the sample, with physical abuse (16.97%) being the most prevalent. Psychiatric comorbidities were highly prevalent (84.47%). The most common reasons for presentation were aggression towards others (36.39%), suicidal ideation (22.56%), and self-injurious behaviors (11.16%). During the visit, 23.27% individuals received a new psychotropic medication, and physical restraint was utilized in 8.56% of visits. 28.27% of patients were psychiatrically hospitalized but 30% of those who needed hospitalization were discharged due to lack of inpatient bed availability. Presence of intellectual impairment (OR 1.97) and aggression (OR 3.57) were associated with a greater likelihood of discharge home due to inability to secure an inpatient bed.

Conclusion: This study adds to the limited literature about individuals with ASD or ID seeking emergency care. The results indicate a highly acute patient population with aggression, suicidal thoughts, and self-injurious behaviors who are frequently prescribed psychotropic medications and face barriers to accessing higher levels of care.

Learning Objectives:

Provide background information about the ASD/ID patient population in the emergency setting.

Explain the methods and results of this 10-year retrospective study.

Examine take home points about this study and what it says about optimal care for these patients and future research.

The increasing volume of children and adolescents presenting to emergency departments (ED) with mental health complaints presents a national crisis. A decade-long longitudinal study revealed that such presentations are trending upward, with an annual rise of 6-10% [1]. This trend will continue to have cumulative effects that challenge our current systems of care. In an effort to inform disposition in situations where aggression and violence are relevant, it is important that emergency medicine providers be informed regarding how to effectively assess the risk for violence in youth.  Youth demonstrating aggressive behavior can present a unique challenge to the ED setting, particularly if they are awaiting inpatient psychiatric treatment and/or possess psychosocial challenges that yield disposition planning difficulties. These situations are not unique to pediatric EDs or academic centers that may have integrated pediatric providers. Community hospitals that may have limited mental health resources might benefit from the implementation of evidence-based violence risk screening that can be applied by a variety of clinical staff to inform risk, treatment disposition, and safety planning.

While the ED presents a uniquely restrictive environment for all persons, some children are more likely to manage related distress through externalized behaviors when compared to adults [1]. Intervention by ED staff who have not received de-escalation training specific to children and youth may subsequently escalate young patients further, thus contributing to the risk of injury for both patients and staff.

There are several widely known youth-specific violence risk assessment tools, such as SAVRY [2], which has moderate validity for those aged 12-18 years old and is well known to the juvenile justice system. Similar well-validated violence risk assessment tools have useful applications, but can be time intensive and difficult to translate to the ED setting as they require specialized training programs. ED providers often have limited time to assess patients who present with psychosocially complex complaints.  Therefore, there is a practical necessity to validate a violence risk assessment tool that balances reliability and brevity.

The Fordham Risk Screening (FRST) has a growing body of data to support its utility in the ED [4] and civil inpatient settings [3]. Recently, the FRST has been integrated as a standard portion of the assessment of patients who present in behavioral or mental health crisis at Maine Medical Center’s (MMC) ED. All patients seen by MMC's Emergency Psychiatry team have been asked FRST screening questions and a subset of these patients are youth who present to the ED seeking crisis evaluation. Therefore, we aim to retrospectively evaluate the utility of the FRST as a clinical tool for evaluating and assessing the risk of violence in children and adolescents. Increasing objectivity of violence risk assessment will allow more thoughtful approaches to patient management in ED settings, and ideally reduce the length of stay and the necessity for pharmacologic interventions, while informing future risk of violence as predicted by an objective screening tool. This work will also inform whether it is possible to streamline risk assessment to a single tool for all ages.

Learning Objectives:

Consider the need and potential clinical utility of violence risk assessment in children and youth specific to emergency departments.

Appreciate the uniqueness of caring for youth in the Emergency Department setting, particularly when there are violence risk factors.

Understand factors that contribute to pediatric violence risk when compared to adults.

Interdisciplinary collaboration can be a complex process that requires time, patience, and understanding of the different points of view and training of each discipline. People working within healthcare often share core values but are often trained in isolation from the other disciplines. Professional silos can occur as each discipline focuses on what they can offer in terms of patient care and staff supports but a strong adherence to “staying in our lane” can also hinder opportunities for shared teaching, case conceptualization, interdisciplinary team responses in crisis. Solid interdisciplinary teamwork is even more challenging when members of the team change frequently, such as who responds to a crisis, staff covering the shift, or rotating attending physicians.

A panel of Directors in safety and security, nursing, and psychiatry and nurse management will describe their collaborative leadership process when navigating serious and complex issues relating to patient and staff safety for inpatient psychiatry and emergency medicine. As a tertiary level hospital in a primarily rural state, complexity of patient needs, recruiting trained staff in a time of extensive staff shortages, and identification of resources are consistent challenges. The team will describe a crisis stabilization unit (CSU) that was developed as a way to meet the needs for patients diagnosed with psychiatric illnesses who experience long waits in the emergency, require increased resources and support, and historically not receiving mental health treatment while they wait for a bed. The presentation will describe the development of two unique staff positions within nursing and safety and security and the successful integration of these staff members on inpatient psychiatry and emergency medicine. Research on interdisciplinary teams in healthcare and use of simulation-based training (e.g., Engum & Jefferies, 2012; Saragih, et al., 2024) provided guidance for development and expansion of training for frontline staff in safety and security and nursing who are responsible for crisis responses and prevention of dangerous behavioral episodes. Discussion will review of challenges, barriers, and the concept of transdisciplinary teams to meet complex patient needs and staff safety.

Learning Objectives:

Participants will understand strategies to support interdisciplinary leadership collaboration for cross training emergency response teams.

Participants will learn about the development of unique staff positions to address staffing shortages and complex patient needs.

Participants will understand the difference between an interdisciplinary and a transdisciplinary process as it relates to developing skilled core response teams.

Background: Currently, youth seeking emergent mental healthcare are often required to complete routine laboratory assessment, regardless of presentation, to ensure “medical clearance” prior to consideration of inpatient psychiatric care. These laboratory tests are often low yield and have the potential to cause significant trauma and avoidable restraint, particularly with youth. Furthermore, this introduces excess cost, spurious lab findings and delays in care for a system that is already constrained by long lengths of stay, inefficiencies, and excess cost. Several states have adopted evidence-based tools, or SMART clearance, and workflows to eliminate the use of routine laboratory findings for medical clearance and based this clearance on clinical presentation and judgment of medical and psychiatric staff.

Methods: We describe the project design and implementation of the MI-SMART tool (adapted from the Sierra Sacramento Valley Medical Society SMART project), via an initiative by the Michigan Department of Health and Human Services, at a large, academic, tertiary care children's hospital in the State of Michigan. This includes initial stakeholder development, including mental health professionals in consultation-liaison psychiatry, inpatient psychiatry and emergency psychiatry, pediatric hospitalists and intensivists, pediatric emergency department (ED) professionals, administrative and information technology staff, as well as partners at Community Mental Health and the Department of Health and Human Services. This stakeholder group met iteratively from January 2024-June 2024 to design workflows in the pediatric ED and psychiatric ED setting, as well as parallel workflows with the inpatient pediatric floors and pediatric critical care setting. The result was the piloting of a electronic medical record navigator with a standardized MI-SMART checklist and template for documentation, page alerts and best practice advisory alerts, workflows, tip sheets, and standardized education to operationalize the implementation of the MI-SMART resources. A data dashboard with key performance indicators was created to track process and outcome measures over time. The first three months of pilot data will also be presented as it relates to the relevant care of the pediatric population in the children's hospital.

Results: We will present stakeholder working group development, collaborative design of the MI-SMART resources, as well as pre-implementation data from the first three months of launching MI-SMART across the children's hospital. This will include review of process measures including number of MI-SMART forms utilized, acceptability of by providers and staff in the ED and hospital setting, number of youth successfully transferred to an inpatient psychiatric facility using the MI-SMART build and resources, time to triage in the ED to completion of the MI-SMART form, time to completion of the MI-SMART form and psychiatric consultation. Additional outcome measures that will be shared include routine labs and diagnostic studies gathered, cost, restraint use, as well as patient and family satisfaction.

Lessons Learned: Use of an evidence-based set of resources to mitigate the use of potentially unnecessary and traumatizing routine labs for medical clearance of youth requiring psychiatric admission may be a feasible, acceptable, and cost-efficient alternative to current medical clearance practice, while improving safety practices and patient, family and staff experience.

Learning Objectives:

Understand current evidence related to best practice for medical clearance of individuals, particularly youth, who require psychiatric admission from emergency settings.

Describe the process of designing an evidence-based tool to employ clinical judgment and best practice in supporting medical clearance of youth in the ED setting, rather than routine labs.

Review process measures and clinical outcomes resulting from initial data gathering on the implementation of the MI-SMART form and resources at a single, academic children's hospital.

Frequently, patients present with psychiatric symptoms and turn out to have a medical etiology. Many of these medical mimics are commonly known such as hypoglycemia and myxedema coma but some are less common which makes them more difficult to diagnosis and manage.  This course will focus on some of the less common etiologies of such psychiatric presentations including catatonia and NMDA receptor antagonist. Evaluation and treatment in the emergency department using case presentations.

Learning Objectives:

To list non-traditional causes for patient presenting with psychotic features or depression symptoms.

To describe the lorazepam challenge for patients with catatonia and expected outcome.

To define procedures needed to determine a definitive etiology for rare medical mimics.

From the discovery of NMDA encephalitis by Josep Dalmau in 2007, autoimmune encephalitis has become an ever expanding group of diseases that is durably changing the landscape of modern neurosciences. These syndromes can initially present with acute or subacute behavior changes sometimes overshadowing subtle neurologic symptoms such as movement disorders or seizures. There is a variety of scenario in which patients with autoimmune encephalitis can, at least initially, be mistaken for patients with primary psychiatric diagnosis. While novel therapeutic approaches have greatly improved outcomes of patients with autoimmune encephalitis, delay in diagnosis remains a major obstacle. As the knowledge around autoimmune encephalitis continues to progress, first line clinicians should be more and more familiar with the specificities of this group of disease in order to close the gap between onset of symptoms and adequate treatment.

This presentation will feature:

1. Basic neuroscientific concepts and outline of the latest discoveries in autoimmune encephalitis such as mechanism of autoantibodies (intracellular vs extracellular; effector vs biological marker), pathogenesis (infectious triggers, paraneoplastic syndromes).
2. Main syndromes and their clinical presentation with emphasis on behavioral symptoms through clinic vignettes.
3. Simplified diagnostic algorithm and decision tree, adapted from the 2016 consensus clinical criteria of autoimmune encephalitis. 
4. Symptomatic management of psychiatric symptoms presented by patients with autoimmune encephalitis and the difference with classic management. 
5. Outline of the neurologic workup: who needs an MRI, an EEG, CSF analysis, malignancy workup. 
6. Outline of the management of autoimmune encephalitis.
7. Recovery and residual psychiatric symptoms and their management. 
8. Future considerations: will an autoimmune panel be sent for every patient in the psychiatric emergency room

Learning Objectives:

Recognize atypical presentations of behavioral emergencies that could suggest an autoimmune encephalitis.

Be familiar with the main autoimmune encephalitis syndromes and their mechanisms.

Know the outline of the workup, treatment, and psychiatric symptomatic management of autoimmune encephalitis.