230 Evaluating Pediatric Behavioral Health Emergency Visits Before and After the COVID-19 Pandemic

Document Type

Conference Proceeding

Publication Date

9-1-2025

Publication Title

Ann Emerg Med

Abstract

Study Objective: Emergency departments (EDs) serve as a critical safety net for pediatric behavioral health (BH) emergencies. Even before the COVID-19 pandemic, pediatric BH visits were rising nationwide. The onset of the pandemic introduced profound psychosocial stressors—including school closures, social isolation, family economic hardship, and grief—that may have exacerbated existing conditions and triggered new mental health crises among youth. These disruptions destabilized both ED and inpatient pediatric BH operations, contributing to delays in evaluation, limited psychiatric bed availability, and increased strain on children, families, and frontline providers. While several studies have documented the impact of COVID-19 on pediatric BH care during the height of the pandemic, there remains limited literature describing how these patterns have evolved during the recovery period. This study analyzes trends in pediatric BH ED visits before and after the pandemic’s onset, highlighting shifts in ED utilization and quality of care. Methods: We conducted a multi-center, retrospective cohort study of pediatric ED visits within a large integrated health system in Michigan, including nine urban and suburban EDs. Data were collected from January 2016 through February 2024 using electronic health records for patients under 18 years with visits coded for BH-related conditions using ICD classifications. The study period was divided into pre-pandemic (January 2016–February 2020) and post-pandemic (March 2020–February 2024) cohorts. Patient demographics, clinical characteristics, and ED operational variables were collected. Variables included visit frequency, ED length of stay (LOS), psychiatric and general medical admission rates, use of physical restraints (violent/self-harm vs non-violent), and frequency of patients leaving against medical advice (AMA). Trends were analyzed using descriptive statistics, two-tailed t-tests, and 12-month rolling averages for temporal visualization. Results: Across the study period, our health system recorded 3,469,947 ED encounters, of which 434,482 (12.5%) were pediatric visits. Among these, 12,307 visits (2.83%) were BH-related. Overall, monthly pediatric BH visits increased by 13.0% post-COVID (from 120.7 to 136.4/month, p <0.01). Pediatric psychiatric admissions rose by 33.7% (21.1 to 28.2/month, p <0.01). ED LOS for pediatric BH patients increased from an average of 475 minutes (7.9 hours) pre-pandemic to over 600 minutes (10+ hours) in the post-pandemic months, representing a 50% increase in ED boarding (p <0.01). Use of violent/self-destructive restraints rose by 39.7%, from 3.7 to 5.17 incidents per month (p <0.01), while non-violent restraint use remained rare and unchanged. AMA rates also rose significantly post-pandemic by 81.0%, from 1.84 to 3.33 cases per month (p <0.01). These trends are visually summarized in the Figure, which highlights the sharp inflection points in BH ED visits, LOS, restraint use, psychiatric admissions, and AMA rates following the onset of the COVID-19 pandemic. Conclusion: The COVID-19 pandemic has had a profound and sustained impact on pediatric BH care in our EDs. The observed increases in visit volume, psychiatric admissions, LOS, restraint use, and AMA departures point to a rising acuity among pediatric BH patients and reflect escalating strain on ED operations. These findings likely highlight systemic gaps in pediatric psychiatric infrastructure and demonstrate the need for expanded pediatric mental health resources, including timely outpatient access, inpatient psychiatric capacity, crisis stabilization units, and enhanced ED support for BH care. Efforts to improve coordination between EDs and community mental health services will be critical to meeting the complex needs of this growing and vulnerable patient population. [Formula presented] No, authors do not have interests to disclose

Volume

86

Issue

3

First Page

S98

Last Page

S99

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