Using your HEADS-ED

Cite this article as:
Sarah Edwards. Using your HEADS-ED, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31842

Paediatric mental health (MH) admissions to emergency departments and hospitals are increasing worldwide, including the UK, USA and Australia1–6. COVID-19 has changed this somewhat, at least in the UK, with a decrease in presentations in the first national lock down7. As the UK and the rest of the world return to the “new normal” in 2021, it is likely that paediatric MH presentations could rise back to pre-covid levels. 

These presentations can be challenging to manage in the emergency department. A variety of tools have been developed to help with history taking and disposition, including the HEEADSSS, HEADS-ED, Risk of Suicide Questionnaire (RSQ) and many others. Here we take look at a recent paper looking at the utility of one of these scoring systems, the HEADS-ED.

Cappelli M, Zemek R, Polihronis C, Thibedeau NR, Kennedy A, Gray C, Jabbour M, Reid S, Cloutier P. The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool. Pediatr Emerg Care. 2020 Jan;36(1):9-15. doi: 10.1097/PEC.0000000000001180. PMID: 28538605

What is HEADS-ED?

The HEADS- ED was developed in 2012 as a tool specifically to obtain a psychosocial history from adolescents in the ED, when it was found found to predict psychiatric consult and admission to inpatient psychiatry with a sensitivity of 82% and a specificity of 87% (area under the receiver operator characteristic curve of 0.82, P < .01). This was a promising finding. 

What was the aim of the paper?

There was a composite primary aim:

  1. To examine the utility and decision validity of the HEADS-ED tool for Paediatric Emergency Department (PED) physicians in guiding consultations to psychiatry and crisis services for patients presenting with mental health concerns.
  2. To examine the concordance between PED physicians and crisis intervention workers (CIWs) in communicating the level of need and action required amongst a sub-sample for the patients. 

Where was the paper set?

This study was conducted in the PED at the Children’s Hospital of Eastern Ontario, Ottawa, a tertiary hospital with 70,000 annual visits a year. 3100 (4.5%) of these are related to mental health concerns. Approximately two-thirds of the MH patients are seen by the PED physicians who either discharge to the community or request a consultation with specialised MH services. Those who don’t need any medical care (other 1/3rd ) are referred directly to the CIWs.

What did they do? 

The HEADS-ED was added to the charts of every child aged 12 to 17 presenting to the ED with a MH concern, completed by the PED physicians. 

Only adolescents who had a complete HEADS-ED were included in the study. If they were younger than 12 or older than 17, or if their presentation was not with a MH concern, then they were excluded from the study.

What did they find? 

There were 2704 mental health presentations during the study period. After various exclusions for wrong age or incomplete or no HEADS-ED assessment, 639 adolescents were included in the study. Of those 140 (22%) were seen by the CIWs.

How good is HEADS-ED at predicting consultation or admission?

The study team looked at how well the screening tool corresponded to consultation for full psychiatric assessment and subsequent admission to inpatient care. 254 (39.7%) children and young people required a consultation by the CIW or psychiatrist. 96 (15.3%) were admitted. 

Chi-squared was applied to each of the seven HEADS-ED items to examine whether the scores correlated to request for consultation and subsequent admission.

  • Inpatient admission was highly associated with higher scores in education, activities and suicidality
  • Consultations with CIW or psychiatry was associated with higher mean HEADS-ED score (mean 6.91)
  • Those who did not need a consultation had a mean score 4.70 (n=254)
  • Those who were discharged had a lower mean score than those admitted (5.28 vs 7.21).

As the HEADS-ED score increased, the likelihood of admission did also. 

How reliable is the score at predicting admission?

  • A HEADS-ED score of 8 or more and a suicidality score of 2 led to 164% more requests for consults from the PED team (relative risk, 2.64; confidence interval, 2.28–3.06) 

How well did the PED and CIW scores correlated?

140 patients had the HEADS-ED completed by both PED physicians and CIWs. The PED physicians rated patients higher on all HEADS-ED items and composite scores compared with CIW; however, not all were statistically significant. 

Agreement on ratings ranged from 61.7% to 92.9% with the highest agreement being suicidality and lowest agreement being activities and peers.

Bottom line – Should I change my clinical practice after reading this paper?

Maybe.

The HEADS-ED can be useful in helping take a psychosocial history in adolescents in the PED.

This may help confer concern when referring to the MH team. It cannot currently be used as a risk assessment as this was a single centre site, in Canada. More work is needed to understand its external validity.  

Final words from Andy Tagg

Patients with mental health concerns are increasing in numbers. Rather than skip over them for something easy it is important that we all get comfortable with asking uncomfortable questions. One of the challenges of formal tools is that they rend to direct the conversation and turn it into a tickbox exercise rather than a free-flowinng conversation. Clinicians need to be able to jump from topic to topic as they develop rapport with the child or young person in front of them.

With four times as many exclusions as inclusions I wonder how well the clinicians did if they did not use the tool. My first instinct would be that clinical gestalt, in experienced clinicians, would be as useful, if not better than the HEADS-ED tool. Where I see the potential value is for those healthcare workers with less experience, that might need a little guidance along the way.

References

1. Lo CB, Bridge JA, Bridge JA, et al. Children’s mental health emergency department visits: 2007-2016. Pediatrics [Internet] 2020;145(6). Available from: https://doi.org/10.1542/peds.2019-1536

2. Irteja Islam M, Khanam R, Kabir E. The use of mental health services by Australian adolescents with mental disorders and suicidality: Findings from a nationwide cross-sectional survey. PLoS One [Internet] 2020 [cited 2021 Jan 3];15(4). Available from: https://doi.org/10.1371/journal.pone.0231180

3. Lawrence D, Johnson S, Hafekost J, et al. The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing [Internet]. Austrialian Government; 2015 [cited 2021 Jan 3]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/content/9DA8CA21306FE6EDCA257E2700016945/$File/child2.pdf

4. Tolentino A, Symington L, Jordan F, Kinnear F, Jarvis M. Mental health presentations to a paediatric emergency department. Emerg Med Australas [Internet] 2020 [cited 2021 Jan 3];1742-6723.13669. Available from: https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13669

5. Williamson A, Skinner A, Falster K, Clapham K, Eades SJ, Banks E. Mental health-related emergency department presentations and hospital admissions in a cohort of urban Aboriginal children and adolescents in New South Wales, Australia: findings from SEARCH. BMJ Open [Internet] 2018 [cited 2021 Jan 3];8:23544. Available from: http://bmjopen.bmj.com/

6. UKParliment. Written questions and answers – Written questions, answers and statements – UK Parliament [Internet]. UIN 181292. 2018 [cited 2021 Jan 3];Available from: https://questions-statements.parliament.uk/written-questions/detail/2018-10-18/181292

7. Ougrin D. Debate: Emergency mental health presentations of young people during the COVID-19 lockdown. Child Adolesc Ment Health [Internet] 2020;25(3):171–2. Available from: https://doi.org/10.1111/camh.12411

8. Cappelli M, Gray C, Zemek R, et al. The HEADS-ED: a rapid mental health screening tool for pediatric patients in the  emergency department. Pediatrics 2012;130(2):e321-7. 

Other useful resources 

Andrew Tagg. Mental Health Screening, Don’t Forget the Bubbles, 2019. Available at:

https://doi.org/10.31440/DFTB.21114

Henry Goldstein. Adolescent Inpatient Psychiatry, Don’t Forget the Bubbles, 2017. Available at: https://doi.org/10.31440/DFTB.11391 

Ester Sabel. The ABC of Self-Harm in Young People – A Psychiatric Approach to Resuscitation. 2019. https://www.rcemlearning.co.uk/foamed/the-abc-of-self-harm-in-young-people-a-psychiatric-approach-to-resuscitation/  

Fixing what once was broken: Ross Fisher at DFTB18

Cite this article as:
Team DFTB. Fixing what once was broken: Ross Fisher at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19345

Spoilers: There are some minor swears at the beginning of this talk so if you are easily offended or are listening with children around then fast-forward 10 seconds or so.

We have all made mistakes. Some are small – like forgetting to get the milk on the way home, some are huge – like forgetting your wedding anniversary. In this closing talk from DFTB18 Ross talks about the ancient Japanese art of Kintsugi. By fixing shards of broken pottery with molten gold artists created something even more beautiful than that which was broken.

 

What if you make a mistake at work? Can you be fixed?

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

DFTB19 has just a couple of main conference tickets left but there are still spots for some of the pre-conference workshops.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

Selected references

Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Advances in pediatrics. 2018 May 7.

Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. InMayo Clinic Proceedings 2017 Jan 1 (Vol. 92, No. 1, pp. 129-146). Elsevier.

You have brains in your head: Eric Levi at DFTB18

Cite this article as:
Team DFTB. You have brains in your head: Eric Levi at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19241

In honour of CrazySocks4Docs Day it seems only fitting that today we release Eric’s talk on mental wellbeing.

Outside of his interest in ears, noses and throats Eric is passionate about our wellbeing. No doctor or healthcare provider is immune to the risk of depression. Andrew Tagg spoke about his own personal struggles at our first conference. Perhaps part of the same spectrum of work potentiated illness is burnout. Characterized by emotional exhaustion, low professional efficacy and high levels of cynicism it is rampant amongst our profession.

#CrazySocks4Docs day was started by a Melbourne cardiologist, Geoff Toogood, with a view to ending the stigma surrounding mental health ion physicians. For more details check out the website here.

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

DFTB19 has just a couple of main conference tickets left but there are still spots for some of the pre-conference workshops.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button

Selected references

Callahan K, Christman G, Maltby L. Battling burnout: strategies for promoting physician wellness. Advances in pediatrics. 2018 May 7.

Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. InMayo Clinic Proceedings 2017 Jan 1 (Vol. 92, No. 1, pp. 129-146). Elsevier.

Two new wellness resources

Cite this article as:
Tessa Davis. Two new wellness resources, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14888

Wellness and wellbeing are current hot topics. Yes, we know that systems need to be changed, and we are all working hard every day to bring about change. But in the meantime, as junior doctors, we still need to go to work every day.

The reality of dealing with life and death situations, the responsibility of decision-making, the shift work and lack of sleep, the inevitable errors, the time away from our families, can all lead to increased stress, anxiety, burnout, and depression.

It’s not a case of telling junior doctors that they have to toughen up, it’s about supporting ourselves to manage our work-life balance as well. That’s our individual responsibility.

And that’s why I was so pleased to see two fabulous, and different, resources launched this week.

First off the starting block was Australia, with WRapEM.org. WRaPEM was built by a team of Queensland-based Emergency Physicians with an interest in wellbeing.

WRapEM has a set of ten modules which are fully designed and collated so that you could run them in your department next week. Modules topics include communication, performance optimisation, reflection, and self-care. Each module has a comprehensive lesson plan consisting of pre-reading material, a guide for facilitators, a guide for learners, and some have slides already prepared, and quizzes for the end of the session. The modules allow user participation and can be adapted depending on how you would like to use them.

Example of the facilitator guide from the Communication Module

Next is You Got This, by a UK team of EM healthcare professionals in Bristol Children’s Emergency Department. This is a wellness website and blog specific to those working in Emergency Departments, which also contains links to a range of organisations that can offer support and advice when we need it. It has a promising wellness blog with some great posts to get their library started. And it has a department-specific wellness section which includes bespoke elements focused on support; activities (like an annual Wellness Week); innovations (things like positive incident reporting); resources (to share with your staff what the local wellbeing support is, social events in the department, wellbeing projects).

 

 

Both of these resources are excellent and they have something different to offer. Here at DFTB, we cannot wait to watch them grow and develop over the coming months, and I look forward to using them in my own department.

The road not taken: what could have been by Andrew Tagg

This is a talk Andy has wanted to give for some time. The idea had been germinating in his head, waiting for the right moment to grow. DFTB17 was it. Since our conference he was lucky enough to be invited to speak on the topic at the ANZICS Combined SIG meeting and was touched, but not surprised, by the number of people who came up to him to tell him their stories.

It is up to all of us to normalize talking about our own mental health, not stigmatize it.

Don't Forget the Bubbles
Don't Forget the Bubbles
The road not taken: what could have been by Andrew Tagg







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