Physician Management of Pediatric Mental Health Patients in the Emergency Department Assessment, Charting, and Disposition Mario Cappelli, PhD,*Þ J. Elizabeth Glennie, MA,*Paula Cloutier, MA,* Allison Kennedy, PhD,* Melissa Vloet, BA,Þ Amanda Newton, PhD,þ Roger Zemek, MD,§|| and Clare Gray, MD*¶ Objective: The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. Methods: A structured chart review was conducted for all MH pre- sentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. Results: The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. Conclusions: This study revealed that the pediatric emergentolo- gists’ charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients. Key Words: mental health, patient discharge, physician management (Pediatr Emer Care 2012;28: 835Y841) T he overall prevalence of mental health disorders for children and youth falls within the range of 15% to 20%, 1Y4 yet it is estimated that only 1 in 6 receive mental health services. 2,3 Interventions to address the mental health needs of these children and youth are limited within a system that is fragmented and underfunded. 4 It is not surprising therefore to find children and youth with mental health complaints turning to the emergency department (ED) for help in a crisis. Indeed, current research shows that pediatric mental health presentations in Canada have increased 15% over a 4-year period (from 2003 to 2006), 5 mir- roring increases in mental health presentations in EDs within the United States 6 and disproportionate to increases in visits for other chronic diseases. 5 There is significant clinical heterogeneity among the mental health presentations of children and youth, and these also vary on the EDs’ locale (ie, country, urban, rural). 5Y7 Beyond basic medical management of the youth who present as a danger to self/others or with severe disordered thoughts, 8 the clinical heterogeneity, combined with the crisis-driven nature of the ED visit, presents significant challenges to the physicians de- livering service to this population. Training and decisional tools are lacking for emergentologists, and the usual psychiatric and psychological assessments for the most part are too long and require intensive training to administer. 9,10 In a recent study, 63% of surveyed pediatric emergency medicine physicians reported that they did not receive adequate training in the evaluation and screening of pediatric mental illness, 11 although in another study 83% of ED physicians indicated that they were confident in dealing with patients with mental health issues. 12 To date, although there are a number of studies that have used chart databases to describe pediatric mental health patients, beyond basic clinical data (eg, presenting problem, discharge diagnosis, consultation to other medical services), little is known on phy- sician’s assessment, documentation, and disposition of these patients. As a start, we conducted this descriptive chart review study with 2 purposes: the primary purpose of this study was to determine the extent of the clinical information that pedi- atric emergentologists recorded in their ED charts. Second, we wished to determine whether the emergentologists used the recorded clinical information for disposition decisions and follow-up recommendations. METHODS Study Setting and Population The Children’s Hospital of Eastern Ontario (CHEO) is a pediatric tertiary care teaching hospital affiliated with the Uni- versity of Ottawa operating within the regional urban and rural areas of the Eastern Ontario Champlain Local Health Integration Network. The Champlain Local Health Integration Network has a population of 1,100,300, with 13.1% consisting of visible minorities, and 10.8% considered to be of low income. Lone parent families make up 23.7% of all families. 13 The hospital’s ED has a total annual volume of approximately 55,000 patient visits for the population younger than 18 years. Of these visits, approximately 1590 (3%) are mental health related. There is a Crisis Intervention Program located within the ED that responds to mental health emergencies of children and adolescents be- tween the hours of 7:30 A.M. and 11:00 P .M. on weekdays and 4:00 P .M. to midnight on weekends. Outside these hours and during ORIGINAL ARTICLE Pediatric Emergency Care & Volume 28, Number 9, September 2012 www.pec-online.com 835 From the *Mental Health Patient Service Unit, Children’s Hospital of Eastern Ontario; †Department of Psychology, University of Ottawa, Ottawa, Ontario; ‡Department of Pediatrics, University of Alberta, Edmonton, Alberta; §Emergency Department, Children’s Hospital of Eastern Ontario; and Departments of ||Pediatrics, and ¶Psychiatry, University of Ottawa, Ottawa, Ontario, Canada. Disclosure: The authors declare no conflict of interest. Reprints: Mario Cappelli, PhD, Mental Health Patient Service Unit, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario Canada K1H 8L1 (e-mail: Cappelli@cheo.on.ca). Financial support for this research was received from the RBC and CHEO Foundations. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0749-5161 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.