Emergency Department

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. 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].