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A Systematic Review of Crisis Interventions Used in the Emergency Department: Recommendations for Pediatric Care and Research

Hamm, Michele P. MSc*; Osmond, Martin MD†‡; Curran, Janet PhD‡§; Scott, Shannon PhD∥¶; Ali, Samina MDCM*∥#**; Hartling, Lisa PhD*††; Gokiert, Rebecca PhD∥‡‡; Cappelli, Mario PhD†‡; Hnatko, Gary MD§§; Newton, Amanda S. PhD*∥**§§

doi: 10.1097/PEC.0b013e3181fe9211
Review Article

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.

From the *Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta; †Children's Hospital of Eastern Ontario, ‡Children's Hospital of Eastern Ontario Research Institute, §Ottawa Health Research Institute, Ottawa, Ontario; ∥Women and Children's Health Research Institute; ¶Faculty of Nursing, #Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta; **Stollery Children's Hospital; ††Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, ‡‡Community-University Partnership for the Study of Children, Youth, and Families, Faculty of Extension, and §§Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.

Reprints: Amanda S. Newton, PhD, Department of Pediatrics, Faculty of Medicine and Dentistry, #8213 Aberhart Centre One, 11402 University Ave, Edmonton, Alberta, Canada T6G 2J3 (e-mail:

Funding for this project was provided by a Knowledge Synthesis grant awarded to the corresponding author from the Canadian Institutes of Health Research (200805KRS). Ms Hamm is supported by a Women and Children's Health Research Institute Graduate Studentship. Dr Curran holds a CIHR Postdoctoral Fellowship in Knowledge Translation. Dr Newton is a CIHR Training Fellow (Career Development Award) in the Canadian Child Health Clinician Scientist Program, in partnership with the SickKids Foundation, Child & Family Research Institute (British Columbia), Women & Children's Health Research Institute (Alberta), and Manitoba Institute of Child Health.

© 2010 Lippincott Williams & Wilkins, Inc.