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Frequency and Correlates of Inappropriate Pediatric Psychiatric Emergency Room Visits

Erin Callahan Soto, MD; Anne M. Frederickson, MD; Harsh Trivedi, MD; Anh Le, MD; Marie C. Eugene, MD; Monica Shekher, MD; Marc Weiskopf, MD; Kelsey Allen-Dicker, MS; Robert Dicker, MD; Victor Fornari, MD; and Christoph U. Correll, MD

Published: August 15, 2009

Article Abstract

Background: Despite increasing pediatric psychiatric emergency room service (PPERS) visits, data are lacking regarding visit characteristics and appropriateness.

Method: This retrospective cohort study
consecutively assessed youngsters aged <‘ ‰18 years between January 1 and December 31, 2002, utilizing data from a 12-page semistructured institutional evaluation form. Appropriateness, severity, acuity, and harm potential of PPERS visits were rated on a Likert scale.

Results: Of 1,062 PPERS patient visits (mean’ ‰±’ ‰SD age: 13.5′ ‰±’ ‰3.1 years, 51.1% male, and 51.2% white), 305 (28.7%) led to hospitalization. Although most patients (68.7%) were in outpatient care, only 21.9% sought and 11.5% completed an outpatient evaluation prior to reaching the emergency room. As many as 34.4% of PPERS visits were somewhat/very inappropriate (optimal care: outpatient evaluation/treatment, even if delayed), 26.6% were somewhat appropriate/neutral (best served by outpatient evaluation/treatment, but timely appointment unavailable), and only 39.0% were fully appropriate. Main reasons for inappropriate PPERS visits were direct emergency room referral from school (P’ ‰=’ ‰.0056) or mental health provider (P’ ‰=’ ‰.0438) without prior psychiatrist evaluation, or unavailable appointment (P’ ‰=’ ‰.0304). Multivariate predictors of inappropriate PPERS visits (r2′ ‰=’ ‰.296, P’ ‰<‘ ‰.0001) included current Global Assessment of Functioning score >’ ‰48 (P’ ‰<‘ ‰.0001), absent suicidal ideation/attempt (P’ ‰<‘ ‰.0001), low harm potential (<‘ ‰4.4, P’ ‰<‘ ‰.0001) and severity
(<‘ ‰4.8, P’ ‰=’ ‰.0136) (1- to 7-point scale) of presenting complaint, and absent psychosis (P’ ‰=’ ‰.0008).

Conclusions: Over one third of PPERS
visits were inappropriate, characterized by better functioning, low harm potential or severity
of presenting complaint, and absent suicidality or psychosis. Development of and improved access to urgent child and adolescent psychiatric outpatient care services in the community and referral agent educational programs may minimize inappropriate PPERS visits.


Submitted: October 29, 2008; accepted January 30, 2009.

Corresponding author: Christoph U. Correll, MD, Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY 11004 (

Volume: 70

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