A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research.
OBJECTIVE
In this systematic review, we evaluated the effectiveness of emergency department (ED)-based management interventions for mental health presentations with an aim to provide recommendations for pediatric care.


METHODS
A search of electronic databases, references, key journals, and conference proceedings was conducted, and primary authors were contacted. Experimental and observational studies that evaluated ED crisis care with pediatric and adult patients were included. Adult-based studies were evaluated for potential translation to pediatric investigation. Pharmacological-based studies were excluded. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Presentation of study outcomes included odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CI). Meta-analysis was deferred due to clinical heterogeneity in intervention, patient population, and outcome.


RESULTS
Twelve observational studies were included in the review with pediatric (n = 3), and adult or unknown (n = 9) aged participants. Pediatric studies supported the use of specialized care models to reduce hospitalization (OR, 0.45; 95% CI, 0.33-0.60), return ED visits (OR, 0.60; 95% CI, 0.28-1.25), and length of ED stay (MD, -43.1 minutes; 95% CI, -63.088 to -23.11 minutes). In an adult study, reduced hospitalization was reported in a comparison of a crisis intervention team to standard care (OR, 0.59; 95% CI, 0.43-0.82). Five adult-based studies assessed triage scales; however, little overlap in the scales investigated, and the outcomes measured limited comparability and generalizability for pediatrics. In a comparison of a mental health scale to a national standard, a study demonstrated reduced ED wait (MD, -7.7 minutes; 95% CI, -12.82 to -2.58 minutes) and transit (MD, -17.5 minutes; 95% CI, -33.00 to -1.20 minutes) times. Several studies reported a shift in triage scores of psychiatric patients dependent on the scale or nurse training (psychiatric vs emergency), but linkage to system- or patient-based outcomes was not made, limiting clinical interpretation.


CONCLUSIONS
Pediatric studies have demonstrated that the use of specialized care models for mental health care can reduce hospitalization, return ED visits, and length of ED stay. Evaluation of these models using more rigorous study designs and the inclusion of patient-based outcomes will improve this evidence base. Adult-based studies provided recommendations for pediatric research including a focus on triage and restraint use.
Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Michele P
MP
Hamm
Martin
M
Osmond
Janet
J
Curran
Shannon
S
Scott
Samina
S
Ali
Lisa
L
Hartling
Rebecca
R
Gokiert
Mario
M
Cappelli
Gary
G
Hnatko
Amanda S
AS
Newton
D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D002648:Child; D015331:Cohort Studies; D015986:Confounding Factors, Epidemiologic; D003419:Crisis Intervention / Q000191:economics / Q000379:methods / Q000458:organization & administration / Q000706:statistics & numerical data; D004630:Emergencies; D004636:Emergency Service, Hospital; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D001523:Mental Disorders / Q000453:epidemiology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D010372:Pediatrics; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011568:Psychiatric Nursing; D012149:Restraint, Physical / Q000706:statistics & numerical data; D014218:Triage