Approximately half of pediatric mental health-related and suicide-related emergency department visits occurred in settings with fewer than 10,000 annual pediatric visits. Visit characteristics and mental health diagnoses varied according to annual pediatric emergency department volume.
Researchers conducted a retrospective cross-sectional exploratory study using the 2016 to 2022 Nationwide Emergency Department Sample (NEDS), which includes data from approximately 20% of US emergency departments (EDs) and uses discharge weights to generate national estimates. The analysis included ED visits among pediatric patients aged 5 to 17 years with a primary mental health diagnosis identified using International Classification of Diseases, 10th Revision, Clinical Modification codes. The study included approximately 5.4 million weighted mental health-related ED visits, representing 1,224,951 unweighted visits.
The primary outcome was presentation to a high-volume pediatric ED, defined as an ED with at least 10,000 annual pediatric visits. Researchers also classified EDs as low-volume with fewer than 1,800 visits, medium volume with 1,800 to 4,999 visits, or medium-high volume with 5,000 to 9,999 visits. Multivariable analyses examined associations between presentation to a high-volume ED and age, sex, race and ethnicity, insurance, household income by zip code, mental health diagnosis, US Census region, and urban-rural location. Researchers separately analyzed visits involving suicide or self-injury.
Among approximately 5.4 million mental health-related ED visits, 50% occurred at high-volume EDs. The remaining 50% occurred at low-, medium-, or medium-high-volume EDs, including 5%, 21%, and 24%, respectively. Patients aged 15 to 17 years accounted for 49% of visits, and 58% of visits involved female patients. Suicide or self-injury was the most frequent diagnostic group at 24%, followed by depressive disorders at 23%.
The pattern was similar among approximately 2.3 million suicide-related ED visits. High-volume EDs accounted for 49% of these visits, compared with a combined 51% at lower-volume EDs. Patients aged 15 to 17 years accounted for 52% of suicide-related visits, and 68% involved female patients.
Mental health-related ED visits increased 24%, from an estimated 668,054 in 2016 to 858,638 in 2022. Suicide-related visits increased 74%, from 224,850 to 391,491 during the same period. Researchers observed increases in suicide-related visits across each pediatric ED volume category.
In adjusted analyses restricted to 2019 to 2022 because of the availability of race and ethnicity data, non-Hispanic Black patients had 1.19 times the odds and Hispanic patients had 1.69 times the odds of presenting to a high-volume ED compared with non-Hispanic White patients. Native American patients had 0.54 times the odds of presenting to a high-volume ED. Patients with private insurance had 1.15 times the odds of presenting to a high-volume ED compared with those with Medicaid, while visits involving substance-related diagnoses had 0.79 times the odds compared with visits involving suicide or self-injury.
Similar patterns emerged in the suicide-related subgroup. Non-Hispanic Black patients had 1.26 times the odds and Hispanic patients had 1.66 times the odds of presenting to a high-volume ED compared with non-Hispanic White patients, whereas Native American patients had 0.51 times the odds. Patients with private insurance had 1.12 times the odds compared with those with Medicaid.
Disposition also differed across ED volume categories. Among all mental health-related visits, 2% of visits at low-volume EDs resulted in admission compared with 16% at high-volume EDs, while short-term hospital transfers decreased from 11% at low-volume EDs to 3% at high-volume EDs. Among suicide-related visits, admissions ranged from 4% at low-volume EDs to 24% at high-volume EDs, while short-term hospital transfers ranged from 19% to 5%, respectively.
The researchers noted that lower-volume EDs may have fewer pediatric-specific mental health resources, including on-site mental health professionals, and may be less likely to offer universal suicide risk screening or brief interventions such as safety planning. They emphasized that EDs should be prepared to provide evidence-based care for pediatric patients with suicide-related concerns regardless of annual pediatric volume.
The study had several limitations. NEDS does not include patient-level identifiers, preventing researchers from accounting for patient-level clustering. Administrative coding may have misclassified demographic characteristics, diagnoses, or mental health severity and complexity. Race and ethnicity data were unavailable for nearly half of the study period, and researchers could not account for the racial and ethnic composition of surrounding geographic areas. The data also did not capture adverse childhood experiences or neighborhood-level factors that could be associated with ED use.
The authors concluded that approximately half of pediatric mental health-related and suicide-related ED visits occurred outside high-volume pediatric EDs, with visit patterns varying by race, ethnicity, and diagnosis. They cautioned that the exploratory findings require replication in additional data sources. “Approximately half of mental health-related and suicide-related ED visits for children occurred in EDs with low, medium, or medium-high annual pediatric volume,” wrote lead author Audrey G. Brewer, MD, of the Division of Advanced General Pediatrics and Primary Care at Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues.
The study was supported by a National Institute of Mental Health grant to Jennifer A. Hoffmann, MD. The funders had no role in the design or conduct of the study. The authors reported no conflicts of interest.
Source: Annals of Emergency Medicine