The mental health of America鈥檚 youth is under duress, and it didn鈥檛 start with COVID-19. It鈥檚 a problem that鈥檚 been a much longer time coming.
In 2023, authors led by Mayo Clinic psychiatrist Tanner Bommersbach, M.D., MPH, in young people鈥檚 use of emergency departments. What they discovered was startling: From 2011 to 2020, the weighted number of pediatric ED visits related to mental health rose from 4.8 million to 7.5 million 鈥� an average increase of 8% a year. 鈥淪ignificant linearly increasing trends were seen among children, adolescents and young adults,鈥� the investigators found, 鈥渨ith the greatest increase among adolescents and across sex and race and ethnicity.鈥�
By 2020, mental health-related visits accounted for more than 13% of all pediatric ED visits 鈥� and then came COVID. Now, several years later, kids are still paying a heavy price.
鈥淚t鈥檚 not just a local problem. There鈥檚 a big boom of pediatric mental health crises nationwide,鈥� said EMS physician Brandon Morshedi, M.D., DPT, FACEP, FAEMS, NREMT-P, FP/CCP-C, assistant medical director for Metropolitan EMS (MEMS) in Little Rock, Arkansas and a faculty physician in the Department of Emergency Medicine at the University of Arkansas for Medical Sciences. 鈥淗ere in our service area, it was our second most common call type in every month of 2023, right behind 鈥榮ick person.鈥� The causes are multifactorial, including a lack of adequate and efficient community outpatient mental health facilities and resources, and the emergency department seems to be where a lot of these kids end up.鈥�
In the Little Rock area, where MEMS transports around 77,000 patients a year, that soaring pediatric mental health call volume started contributing to crunches in the emergency department: All the service鈥檚 mental and behavioral health patients under 18 had to be taken to a single facility, Arkansas Children鈥檚 Hospital (ACH), to be checked out and medically cleared before being transferred to a behavioral health center. 鈥淢EMS was transporting about two behavioral patients a day, and they were seeing a lot of additional behavior patients arriving by private vehicle and other EMS providers,鈥� recalled MEMS Clinical Manager Mack Hutchison. Medics ended up delayed, and distressed kids endured long waits.
The situation wasn鈥檛 working well for anyone 鈥� but MEMS already had a solution in hand.
鈥業T鈥橲 BEEN A WIN ALL AROUND鈥�
Since 2020, Metro EMS had been using the platform for communication. An app-based system that unifies care teams across departments and organizations, it links MEMS crews to partners at hospitals and elsewhere to simplify and streamline their joint care of patients. The platform brings all communications onto one dedicated patient channel, replacing radio reports, phone calls and other methods. This allows EMS to document their assessments and initial interventions, then share a detailed prearrival notification with ED counterparts and other care providers. This expedites care processes, reduces duplication of communication, improves accuracy and ensures everyone has the same common operating picture.
With funding from the state, MEMS initially adopted Pulsara for care of time-sensitive emergencies like stroke, STEMI and trauma, where it enabled sending key information ahead and sharing it with specialists like neurologists and cardiologists. The platform has some in these areas.
鈥淭he genesis of that was through the governor鈥檚 STEMI [ST-elevation myocardial infarction] Advisory Council,鈥� said Hutchison, a member of that group. 鈥淎mong the first things we looked at was whether all the EMS agencies in Arkansas could obtain 12-lead EKGs, and if so, could they transmit them ahead to the hospital?鈥�
Most could get the 12-lead, the committee discovered, but many couldn鈥檛 transmit them to the hospital. The Pulsara platform was their solution, and the state also helped hospitals obtain it. It worked so well that hospitals鈥� use quickly expanded from time-sensitive issues to nearly all categories of patient presentation.
So why not kids in crisis? Well, conventional EMS wisdom has discouraged such an approach.
鈥淎s medics, we always thought pediatric behavioral patients had to be medically screened before they could go to a behavioral hospital,鈥� Hutchison said. 鈥淏ut in the ER, they鈥檙e waiting for up to 24 hours and taking up bed space and resources other, sicker children could be using.鈥�
It made sense to take such children directly to their needed specialists, circumventing the busy children鈥檚 hospital entirely 鈥� if it could be done safely. So, MEMS assembled a committee that examined the issue and worked on a protocol to allow it.
The committee came up with a protocol that let EMS crews conduct rapid medical screenings and, if young behavioral health patients meet the required criteria, take them directly to behavioral health facilities.
The criteria are straightforward: Patients can bypass the ED unless they have an injury requiring medical attention, a questionable ingestion, a chronic medical diagnosis or are acutely ill. If the initial responding medics determine a patient is eligible for direct transport, they use Pulsara for a quick call to line up a suitable destination (MEMS has five to select from for these patients) and add providers there to the patient鈥檚 care channel. They fill remaining patient info into the app en route, so receiving staff are informed and prepared when they arrive.
In the program鈥檚 first 11 months, MEMS encountered 4,424 psych patients, of whom 758 were pediatric. Of those, 379 were taken to emergency departments, and 58 weren鈥檛 transported 鈥� but 321 were taken directly to behavioral facilities under the new protocol, avoiding the ED. None needed subsequent 911 help or bounced back. That amounted to a 46% reduction in the number of pediatric psych patients requiring clearance at ACH (a rate that has continued to improve even since Pulsara featured MEMS鈥� use in a ).
鈥淏eing able to take pediatric patients straight to truly definitive management, and not having to go sit on the wall in a hospital that can鈥檛 accept these patients for an extended period of time, makes everybody happier,鈥� said Morshedi. 鈥淭he medics are happier, Arkansas Children鈥檚 Hospital is happier, the behavioral health facilities are happier because they鈥檙e getting patients straight from the field, and the parents usually come with them for the intake process. We get our crews back in service quicker. It prevents secondary transfers. So, it鈥檚 been a win all around.鈥�
And there鈥檚 room for additional victory: Of the 379 young patients who went to the ED, 276 actually qualified for the new protocol but couldn鈥檛 go straight to behavioral facilities due to reasons like bed availability, facility response timeliness and family preference.
The program has been so successful that MEMS is now piloting a similar approach for adults.
LOST REVENUE REDISCOVERED
isn鈥檛 mandatory for EMS personnel in Arkansas, but its benefits and ease of use have prompted lots of providers to embrace the app. And while it does represent a new step in the prehospital care of patients, it replaces multiple others.
鈥淭he medics see for themselves that it works and improves times and patient outcomes, but you have to kind of balance the number of things you鈥檙e asking them to do out there on an encounter,鈥� said Hutchison. 鈥淲e still use our ePCR software too, but we try to find some give and take. What can we take away that you don鈥檛 have to do if you use Pulsara? One of those things is the radio report to the hospital. So there were little things that helped people come on board. That also included partnering with hospitals and doing studies. After Pulsara was implemented, for example, we had one stroke facility that decreased door-to-needle times by about 58%. So sharing that success with the medics helps persuade more medics to use it.鈥�
The platform has also been useful to Air Evac Lifeteam, the air-medical giant that operates in 18 states. In Arkansas it lets Morshedi, the service鈥檚 medical director, video conference easily with his flight crews.
鈥淚t鈥檚 basically like FaceTime but all within the Pulsara app,鈥� he said. 鈥淭he crews just add me or any of the physicians here as a consult into the channel they already have between them and the receiving facility, or even if they don鈥檛 have a facility assigned yet. We can engage in audio and video calls, lay eyes on the patient and talk directly to them. We see this being useful with our refusals and nontransports.鈥�
Arkansas also recently passed a bill that codifies principles of the federal government鈥檚 late ET3 (Emergency Triage, Treat and Transport) plan into state law. This allows EMS to navigate lower-priority patients to alternative destinations or treat and release them and still get reimbursed by Medicaid 鈥� but it requires a physician consult.
鈥淲e knew then we鈥檇 be using Pulsara a lot more,鈥� added Morshedi. 鈥淲e have a nontransport rate of 15%鈥�20%, right around the national average. Imagine if you could recuperate the revenue lost from not transporting those patients! So this could be a platform for agencies to generate some revenue by doing what they鈥檙e doing anyway. They鈥檙e not going to increase their nontransport rate just so they can go make more money, but it鈥檚 a way to stop losing money.鈥�
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