Seattle Children's Provider News

ED Patient Surge for Mental and Behavioral Health

From: Dr. Jeff Ojemann, SVP and Chief Medical Officer, Bonnie Fryzlewicz, SVP and Chief Nursing Officer and Dr. Tony Woodward, ED Medical Director

Seattle Children’s continues to see an extremely high number of pediatric patients seeking care for mental and behavioral health emergencies.  Thank you for your continued efforts to manage lower-acuity complaints, including lower-acuity mental and behavioral health concerns, in outpatient settings when appropriate. (See the Nov. 9 Special Update for a list of resources and how you can help.)

The ED is also seeing increased census in viral illnesses (see our Nov. 16 update on RSV/synagis/nirsevimab). RSV activity is high and has not peaked yet. Influenza activity is starting to rise locally.

Patients experiencing any type of medical emergency, including a child at imminent risk of harm to self or others, should seek immediate care at an emergency department.

Code yellow activated

We have activated a code yellow to manage our response (a code yellow opens an emergency operations center and formalizes an incident command structure for rapid communication and implementation of plans). We have implemented surge plans that help increase our capacity, and we are employing new tactics to allow us to better manage surges of ED patients and maximize use of beds in the Psychiatry and Behavioral Medicine Unit. However, we continue to see a significant proportion of our ED beds occupied by mental and behavioral health patients awaiting disposition, and some families may experience long waits.

The challenge of children and youth “stuck” while awaiting their next step in care is a crisis nationwide. Across Washington State hospitals, levels of patients awaiting disposition are at an all-time high.

Other actions we are taking 

While we recognize that systemic, statewide solutions typically take time to identify and implement, we are working with statewide partners to add resources and improve processes outside of Seattle Children’s. This is an important part of working toward long-term, sustainable solutions and will likely continue in the months ahead.

In order to raise awareness of these challenges and share relevant resources, we have reached out to numerous partners including leadership of state agencies, hospital partners through the Northwest Healthcare Response Network (NWHRN), key state legislators, Washington’s federal congressional delegation, the Washington State Governor’s Office, and local partners including School Based Health Centers and Public Health – Seattle and King County.  We continue to collaborate to identify and advance solutions in the short-, medium-, and long-term.

Thank you for your continued partnership.

Please contact Tony Woodward, ED Medical Director and Division Chief, with any suggestions, questions or concerns: [email protected]

High-Transmission Protocols Effective Nov. 20 Include Masking and Visitor Restrictions

From: Ruth McDonald, VP and Associate Chief Medical Officer (Hospital Operations) and Chief Medical Operations Officer; Bonnie Fryzlewicz, SVP and Chief Nursing Officer; and Danielle Zerr, Medical Director of Infection Prevention

Due to elevated transmission rates of respiratory diseases – specifically, RSV rates – Seattle Children’s has updated its masking, PPE, visitor and other policies. These changes took effect Monday, Nov. 20.

Masking changes

• Everyone in clinical areas – workforce members, patients and families – will be required to wear a mask.
• Masking will be recommended in non-clinical buildings and spaces.

Personal protective equipment (PPE) changes

• Eye protection is required for all clinical encounters.

Visitor policy changes

• Inpatient:
  • Four people (caregivers and/or adult visitors) allowed at bedside at a time (two dedicated caregivers may stay overnight).
  • No sibling visitors under 18 years. Patients who have or are anticipated to have an inpatient stay of 30 days or more are permitted to request a weekly sibling visitation.
  • No non-sibling visitors under 18 years.
• Ambulatory:
  • A total of 4 caregivers and siblings are permitted to accompany the patient to their visit. It is preferred that siblings stay home and caregivers are limited.

Why did we update our policies on Nov. 20?

• Seattle Children’s, along with other healthcare systems across the region and the Northwest Healthcare Response Network (the Network), has adopted interim thresholds for universal masking to prioritize the health and safety of patients and employees.
• The Network’s latest update on masking in acute care and outpatient clinics is here.

For more information: Find our updated policies on our website.

From: Dr. Danielle Zerr, Medical Director of Infection Prevention and Seattle Children’s Pharmacy and Therapeutics Committee

Seattle Children’s began administering palivizumab (Synagis) on Nov 2 due to increasing RSV rates. We ask that community providers with patients who need Synagis provide it directly rather than referring patients to Seattle Children’s, due to capacity constraints at the hospital. Eligibility for palivizumab and nirsevimab follows the CDCs updated guidance.

A reminder about Nirsevimab:

• Nirsevimab is available at our hospital campus in limited supply for inpatients nearing discharge and outpatients with established subspecialty care at Seattle Children’s who do not have access through their PCP.
• Nirsevimab is not available at our Urgent Care sites.

For more information:

• CDC’s updated guidance (10-23-23) – addresses limited availability of product
• RSV Update | Washington Vaccine Association (10-12-23)
• AAP’s Nirsevimab FAQs
• Find family-facing resources about RSV at the end of the article “What Parents and Caregivers Should Know About RSV” (On the Pulse, 10-24-23)

From: Dr. Jeff Ojemann, SVP and Chief Medical Officer, Bonnie Fryzlewicz, SVP and Chief Nursing Officer and Dr. Tony Woodward, ED Medical Director

Seattle Children’s is experiencing an extremely high number of pediatric patients seeking care for mental and behavioral health emergencies. Our Emergency Department (ED) remains a resource, if needed, and we wish to alert you to some limitations in our capacity and provide alternative resources.

This extremely high demand is leading to up to 50% of our ED beds being occupied by mental and behavioral health patients awaiting disposition. We are triaging to see patients with the most urgent concerns first. Some families may experience long waits.

Patients experiencing any type of medical emergency, including a child at imminent risk of harm to self or others, should seek immediate care at an emergency department.

How you can help:

1. Please continue to identify and manage lower-acuity complaints in outpatient settings, including urgent care, to help maintain ED capacity for higher-acuity concerns. This includes managing lower-acuity mental and behavioral health concerns in outpatient settings as much as possible. See below for resources.
2. Before sending your patient to the ED, contact our Mission Control team with as much notice as possible at 206-987-8899. This helps us plan for your patient’s arrival. In appropriate instances, we may be able to directly admit your patient to the hospital or arrange an urgent ambulatory clinic visit in lieu of an ED visit.
3. Please be aware that our inpatient Psychiatry and Behavioral Medicine Unit (PBMU) currently has no capacity for new patients. At this time, we are referring pediatric patients requiring a psychiatric inpatient admission to all appropriate facilities in Washington State.

4. Help set realistic expectations about an ED visit and/or inpatient admission with children, families and partners. 

• An ED visit for mental or behavioral health typically involves an evaluation to determine if the child needs an inpatient psychiatric admission or is appropriate to discharge home. Patients and families should be prepared for potentially longer wait times.
• As noted earlier, referrals to the PBMU will experience significant wait times and may not result in admission; we are asking all external partners to consider referring patients who need inpatient admission to all appropriate inpatient pediatric psychiatric facilities in Washington and consistently re-assess need for inpatient admission.
• Patients seen in our ED who need inpatient psychiatric admission will be referred to all appropriate inpatient pediatric psychiatric facilities in Washington.
• An inpatient psychiatric admission is typically 5 to 10 days and focused on acute crisis stabilization. It is not a long-term placement.

Mental and behavioral health resources for providers:

Resources that may help you manage patients in primary or urgent care instead of sending to the ED:

1. The Partnership Access Line (PAL) supports primary care providers (doctors, nurse practitioners and physician assistants) with questions about mental and behavioral health care such as diagnostic clarification, medication adjustment or treatment planning. Our child and adolescent psychiatrists are available to consult during business hours.
2. The Washington Mental Health Referral Service connects patients and families with evidence-supported outpatient mental and behavioral health services in their community. This free telephone-based referral service provides thorough mental and behavioral health referrals for children and teens 17 and younger from across Washington.
3. Seattle Children’s First Approach Skills Training (FAST) programs are designed to provide brief, evidence-based behavioral therapy for youth and families with common mental and behavioral health concerns in settings such as primary care clinics or schools, where longer-term treatment is not typically provided. Program materials, as well as engagement and assessment tools for clinicians, are available on the Seattle Children’sFAST Website.
4. Seattle Children’s online mental and behavioral health hub: Provides resources for families and caregivers to reference for their child’s mental and behavioral health and wellness. You can learn about common mental and behavioral health problems in children and teens, how to recognize the signs of a problem and crisis and how to help your child or teen as well as what services are available.
5. Family Resource Center – Child Mind Institute: Provides information for families and caregivers to help support children who are struggling with mental and behavioral health or learning challenges.
6. Strategies for Clinical Settings for Youth Suicide Prevention (aap.org): Provides a clinical pathway for addressing suicide prevention in pediatric practice.
7. Mental Health Practice Tools and Resources (aap.org): Provides resources to help providers promote healthy mental development and address mental and behavioral health concerns.
8. Algorithms and other PCP resources for 65+ conditions

Thank you for your continued partnership.

Please contact Tony Woodward, ED Medical Director and Division Chief for any suggestions, questions or concerns: [email protected].

Emergency Department volumes

Last month, the Emergency Department (ED) began an enhanced care process to help address ongoing staffing and space constraints. Elements include a provider-in-triage and use of lobbies as spaces where patients can receive some types of care and wait for results. This means that patients may see more than one provider during their stay (in triage and again as part of a care team), and they may have movement to and from lobbies while we maximize the use of each ED room. These changes have helped reduce wait times for patients, shorten their length of stay and reduce our left-without-being-seen rates.

When referring patients and families to the ED, please let them know that things might seem different than what they have previously experienced.

As a reminder, please call Mission Control when sending patients to the ED to help us prepare: 206-987-8899.

We welcome questions from you as well as our patients and families.

Urgent Care update

Our Urgent Care (UC) sites continue to see high patient volumes, with September 2023 volumes 40% higher than September 2022. Over the past 12 months, our UC sites have seen 17,000 more patients than in any prior 12-month period. We have expanded capacity rapidly to keep pace, offering telehealth this year for the first time and offering expanded hours at our Seattle location.

Despite this significant expansion, we still face capacity constraints. We can take a limited number of walk-ins each day, but the only way for families to guarantee being seen is by reserving a spot either online or by calling our scheduling team. Please continue to encourage families to reserve a slot before coming to urgent care.

Please refer to our Emergency vs. Urgent Care Referral Guide when needed.

Read full post »

Respiratory syncytial virus (RSV) rates at Seattle Children’s and statewide remain below threshold. We are not yet in RSV season. Nirsevimab (Beyfortus) continues to be available at Seattle Children’s hospital campus for inpatients nearing discharge and outpatients meeting criteria (those who do not have a PCP or who will age out of eligibility before their PCP has a supply). Nirsevimab is not available at our Urgent Care sites.

For more information:

• RSV Update | Washington Vaccine Association (10-12-23)
• CDC’s updated guidance (10-23-23) – addresses limited availability of product
• AAP’s Nirsevimab FAQs
• Find family-facing resources about RSV at the end of the article “What Parents and Caregivers Should Know About RSV” (On the Pulse, 10-24-23)

COVID-19 vaccines at Seattle Children’s

• Seattle Children’s is offering the 2023–2024 monovalent COVID-19 vaccine to patients at the hospital campus and Seattle Children’s Odessa Brown Children’s Clinic (OBCC).
  • Moderna’s monovalent COVID-19 vaccine will be offered to our patients staying in the hospital or coming for a clinic visit at the hospital campus.
  • Pfizer’s monovalent COVID-19 vaccine will be available to patients visiting OBCC.
• The COVID-19 vaccine is not available to patients at other locations.

For more information visit our COVID-19 page.

Families of young children needing an evaluation for autism are currently facing wait times at Seattle Children’s of just over one year. For children ages 5 and older, the wait time for an evaluation is more than three years.

“Seattle Children’s is an excellent place to get an evaluation for autism but it’s not the only place and not the quickest,” says Jennifer Mannheim, ARNP, Autism Center diagnostic lead. “We want families and their primary care providers to know their options to be seen sooner if possible.”

When to refer to Seattle Children’s versus a community provider

For many children, evaluation by a community provider is an excellent option, particularly if their primary care provider (PCP) is moderately or highly confident that they meet criteria for autism. Research shows community providers excel at “ruling in” autism; if they think a child has autism, they are usually correct. Community providers typically are able to complete an autism evaluation of younger children with developmental concerns much sooner than Seattle Children’s.

If a PCP is less confident that their patient meets the criteria for autism, we recommend referring them to a center with a multidisciplinary team such as Seattle Children’s or University of Washington, where providers have expertise in evaluating more complex developmental concerns. This includes children who may have ADHD, multiple mental health diagnoses and/or psychosocial stressors.

Read full post »

Newly diagnosed cancer patients in their 20s may be referred to a pediatric cancer center for treatment rather than an adult cancer center. Some of the nation’s top children’s hospitals have Adolescent and Young Adult (AYA) programs specifically designed for this special population.

“We want every young adult with cancer to get the best care possible, access to cutting-edge clinical trials, and have the best odds at survival. In many cases, for a variety of reasons, the best place for them to go is a pediatric cancer center,” says Dr. Tyler Ketterl, medical director of the Seattle Children’s AYA Cancer Program. Pediatric oncologists at Seattle Children’s Cancer and Blood Disorders Center (CBDC) routinely treat patients in their late teens and 20s and even some patients in their 30s.

Dr. Ketterl lists the primary reasons that pediatric treatment is the best choice for many young adults. Read full post »

Breech presentation at birth or any point during the third trimester is a particularly strong risk factor for developmental hip dysplasia, even for infants with a normal physical exam. Orthopedics has updated the algorithm for hip dysplasia to reflect updates from the American Academy of Orthopedic Surgeons (AAOS) Clinical Practice Guidelines.  The update includes a recommendation to perform the following for breech babies (breech at birth or any point during third trimester): a six-week screening ultrasound followed by a single AP pelvis radiograph at 6 months of age.

You can find algorithms for dozens of other conditions at seattlechildrens.org/algorithms.

Seattle Children’s has updated its website for healthcare professionals with a fresh new look that offers easy navigation to an array of helpful resources, from algorithms to CMEs and more. We hope you will find it easier than ever to find what you need.

Visit seattlechildrens.org/providers

Here are a few of the most popular provider-facing resources found on our website:

Read full post »

FAST resources for PCPs

FAST offers brief, evidence-based behavioral therapy for many common mental health concerns such as depression and anxiety. The program and materials are intentionally designed for use in settings where kids would not typically receive longer-term treatment, such as primary care clinics and schools.

You can learn more about FAST and check out their free resource materials for providers on their website.

Resources include two-page “snapshot” handouts in English and Spanish that can be given out to kids and families as a first step prior to referring them for clinician-guided intervention. They cover these common mental health conditions: Read full post »