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Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 44-52

Inpatient psychiatric facility exclusionary criteria and the emergency pediatric psychiatric patient

1 Academic Chair and Program Director, Emergency Medicine Residency Program, Merit Health Wesley, Hattiesburg, Mississippi, USA
2 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
3 Department of Emergency Medicine, Keck School of Medicine of USC, Los Angeles, CA, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Veronica Tucci
Academic Chair and Program Director, Emergency Medicine Residency Program, Merit Health Wesley, Hattiesburg, Mississippi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-5568.209838

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Background: Mental health and behavioral emergencies account for approximately 7% of emergency department visits for pediatric patients. Patients with mental health emergencies requiring inpatient admission pose a particular challenge to emergency clinicians. Patients must be “medically cleared” and criteria for medical clearance vary from hospital to hospital, and can change quickly within hospitals as well. Furthermore, psychiatric hospitals have exclusionary criteria, limiting the patients who can be transferred for psychiatric inpatient care. The objective of this study was to describe the exclusionary criteria and requirements for medical clearance in pediatric patients with mental illness in one large U.S. city.
Methods: The exclusionary criteria and required laboratory and ancillary testing of all psychiatric inpatient hospitals accepting pediatric patients in Houston, Texas were catalogued.
Results: Seven psychiatric hospitals accept pediatric patients and the requirements for admission vary by hospital. No hospitals accept patients with severe intellectual disabilities or autism or patients unable to independently perform activities of daily living. One hospital accepts pregnant patients. Hospitals have different testing requirements for medical clearance with the majority requiring a complete blood count, creatinine phosphokinase and blood alcohol level.
Discussion: We have identified multiple vulnerable populations, including intellectually disabled and patients with autism, who cannot be admitted for necessary psychiatric inpatient treatment and subsequently require emergency department boarding until an alternate treatment plan can be developed. Emergency departments are not an ideal therapeutic environment for patients with psychiatric emergencies, especially patients with intellectual disabilities and autism. Facilities able to provide specialized care are needed. Furthermore, we suggest that national guidelines be developed to standardize an evidence-based medical clearance process.
The following core competencies are addressed in this article: Patient care, Systems-based practice.

Keywords: Exclusionary criteria, medical assessment, medical clearance, pediatric psychiatric patient, mental illness

How to cite this article:
Tucci V, Moukaddam N, Matorin A, Shah A, Onigu-Otite E, Santillanes G. Inpatient psychiatric facility exclusionary criteria and the emergency pediatric psychiatric patient. Int J Acad Med 2017;3:44-52

How to cite this URL:
Tucci V, Moukaddam N, Matorin A, Shah A, Onigu-Otite E, Santillanes G. Inpatient psychiatric facility exclusionary criteria and the emergency pediatric psychiatric patient. Int J Acad Med [serial online] 2017 [cited 2023 Jan 31];3:44-52. Available from: https://www.ijam-web.org/text.asp?2017/3/1/44/209838

  Introduction Top

Recognized acute mental health and behavioral emergencies currently account for approximately 7% of all pediatric emergency department (ED) visits in the United States.[1] The American Psychiatric Association (APA) defines a psychiatric emergency as “an acute disturbance in thought, behavior, mood, or social relationship, which requires immediate intervention as defined by the patient, family, or social unit.”[2]

In 1996, The World Health Organization estimated that by the year 2020, neuropsychiatric disorders would be in the top five conditions impacting morbidity, mortality, and disability in the pediatric population.[3] Suicide is now the second leading cause of death in the US in 10–14 and 15–24 year olds.[4]

Pediatric mental health emergencies can be linked to suicide, mood disorders, psychosis, and trauma, among others. The United States Department of Health and Human Services and the National Institute of Mental Health has reported that more than 13 million children and adolescents require mental health or substance abuse services.[5] Suicidal patients may present as trauma patients (e.g., motor vehicle accident) or intoxicated patients without any mention of self-harm. Patients with primary mental health disorders may also present to the ED with vague, somatic complaints instead of psychiatric chief complaints.

According to the Centers for Disease Control,[6] among students in grades 9–12 in the US during 2013, a staggering 17.0% of students seriously considered attempting suicide in the previous 12 months, 13.6% of students made a plan about how they would attempt suicide in the previous 12 months, 8.0% of students attempted suicide one or more times in the previous 12 months, and 2.7% of students made a suicide attempt that resulted in an injury, poisoning, or overdose requiring medical attention.

Although outpatient care may be preferable for pediatric patients experiencing psychiatric or behavioral issues, most adolescent patients who had attempted suicide were not recognized as suicidal by their primary care physicians.[7] The failure of primary care to recognize suicidality in children and adolescents places a higher burden on other providers including school and social workers as well as ED staff.

Given an emergency physician's limited knowledge of their patient's behavior and affect at baseline and the time constraints in which the emergency physician can form a therapeutic bond, emergency physicians may be even less equipped to diagnose suicidality in pediatric populations than primary care providers and need to utilize screening tools to ferret out patients at risk. One study by Kemball et al. found that 75% of the patients who disclosed suicidal ideation on a computer survey had not presented to the ED complaining of suicidal ideation or a mental health problem.[8] Another study by Claassen and Larkin found that 8% of the patients presenting to the ED for medical complaints were found to have suicidal ideation on screening.[9]

Despite the obstacles to diagnosing and treating psychiatric conditions in the ED, it is essential that emergency physicians be able to recognize suicidality in children and adolescents for several reasons.

First, recent studies show that there are an increasing number of pediatric patients presenting to the ED with primary psychiatric complaints. As frontline providers, EPs must adeptly triage children and adolescents with behavioral and psychiatric emergencies and be comfortable either hospitalizing or discharging them with appropriate follow-up. Next, in addition to the patients presenting with clear psychiatric pathology, emergency staff should ask all pediatric patients about suicidal ideation as many teenagers who present to the ED with medical complaints endorse suicidal thoughts and plans. Failure to do so, results in substantial morbidity, potential mortality, and increased health-care utilization and costs.

Pediatric mental health presentations to the emergency department

Several layers of difficulty complicate the management of mental health presentations to the ED for pediatric and adolescent patients. Most EDs are manned by emergency physicians. In 1997, less than one-quarter of children's hospitals in the United States had psychiatric and behavioral services available in the ED.[10] Thus, the burden of diagnosing, stabilizing, and managing emergency mental health conditions has historically fallen on the shoulders of the emergency physician.

The next step for the ED physician is to get the patient safely transferred to an inpatient psychiatric unit. To many emergency physicians and emergency psychiatrists, the process of admitting pediatric psychiatric patients to inpatient hospitals is akin to a game with complex rules known only to a select few which the inpatient facilities can change without notice. Denials for admissions or delays in the process contribute to ED boarding and further burden already scarce ED resources.

In this manuscript, the challenges of navigating the requirements for psychiatric inpatient pediatric hospitalizations are explored through the lens of the local exclusionary criteria in Houston, Texas, the third largest city in the United States.

Getting a child or teen to an inpatient psychiatric unit - the process

Briefly, admitting patient to a psychiatric unit requires a “medical clearance” (see below), filling out a form to the facility of choice, completing a “doc-to-doc” or “peer-to-peer” communication between transferring physicians, and getting administrative clearance for the patient. As pediatric patients cannot typically provide consent for admission, locating and enlisting the help of the patient's guardian is an additional legal aspect of admission protocols. The process can go wrong at any stage.

What must a patient do while boarded in the ED? They first have to get medically cleared: as front line providers, emergency physicians complete an initial assessment of patients presenting with psychiatric manifestations to ferret out any madness mimickers or stabilize any concerning medical conditions in a process commonly referred to as “medical clearance.” This process is problematic and fraught with uncertainty because at the time of this paper, there is no standardized approach to “medical clearance” or any uniform criteria with respect to minimum testing.[11] Although a full discussion of medical clearance is beyond the scope of this paper, we summarize the medical clearance process as follows. First, providers should conduct an appropriate history and physical examination on every child and adolescent regardless of the nature of their chief complaint. Next, targeted radiographic and laboratory testing may also be needed to assess the medical stability of the patient.[12] However, even after the patient has been fully evaluated and assessed/cleared by emergency physicians, the patient may still be denied admission to an inpatient unit or facility due to failing to meet “exclusionary criteria,” leading to delays in transfer.

In 2008, 1400 ED directors were surveyed by the American College of Emergency Physicians (ACEP) about ED conditions including boarding (formally defined as a patient remaining in the ED after the patient has been accepted to an inpatient bed but has not yet been transferred to an inpatient unit).[13] Almost 80% of the directors reported that emergency psychiatric patients were boarded in their EDs, and 62% of the directors responded that they had no psychiatric services for patients who are being boarded in the ED.[14] A separate survey of ED administrators conducted in 2010 found that more than 70% had experienced patients with behavioral emergencies boarding for 24 hours (h) or longer and 10% had experienced patients boarding for over a week.[15] With respect to pediatric patients specifically, one study published in 2011 by Wharff et al. noted a mean boarding time of 22.7 h and also that patients with intellectual disabilities including autism and mental retardation as well as those with suicidal ideation were more likely to be boarded in the ED.[16]

From national to local-exploring barriers to psychiatric admissions

The authors' experience mirrors this trend of boarding and extended lengths of stay at Ben Taub Hospital, a level one trauma center in Houston, Texas. Our hospital does not have a dedicated pediatric inpatient emergency psychiatric center and all children and adolescents requiring inpatient psychiatric treatment must be transferred to appropriate facilities.

In 2014 (personal communication from Ben Taub leadership), about 10% of the pediatric patients evaluated at our hospital had psychiatric complaints. In 2015, that number went up to 12.6%. Pediatric patients with medical complaints had an average length of stay of 5 h and 38 min if discharged, and an average length of stay of 6 h and 57 min if admitted/transferred. However, discharged pediatric psychiatric patients had an average length of stay of 16 h and 23 min and patients admitted to inpatient psychiatric facilities had a length of stay of 21 h and 37 min. From 2014 to 2015, the lengths of stay increased for both discharged and admitted psychiatric patients, with those numbers rising to 16 h and 50 min and 29 h and 31 min, respectively. For comparison purposes, in 2015, adult psychiatric patients had only a slightly longer length of stay at 30 h and 8 min despite many of them having more complex medical problems requiring intervention and stabilization before transfer.

As mentioned above, previous studies found that 7% of pediatric ED visits had primary psychiatric complaints. At our hospital, we see almost double that rate of psychiatric chief complaints in our pediatric patient population, with an increasing trend. Moreover, pediatric patients with mental health or behavioral issues have a length of stay three times longer than that of patients with primarily medical problems, with most of the difference being due to the complexity of the admission/transfer process.

  Results Top

Exclusionary criteria for inpatient psychiatric facilities

[Table 1],[Table 2],[Table 3] and [Figure 1] represent the various exclusionary criteria and testing requirements of the inpatient psychiatric facilities accepting children in the Houston Metro area. Exclusionary criteria are rules established by individual psychiatric facilities regarding preexisting medical conditions such as autism or other patient factors which bar a patient from being admitted, as explained above, and often include necessary medical equipment such as indwelling gastric tubes which require specialized nursing care. Of the 16 inpatient psychiatric facilities in the Houston-Galveston Metro area, less than half will admit pediatric or adolescent patients, making age one of the most common exclusionary criteria. In addition to age, many of the listed inpatient psychiatric facilities require laboratory studies, assessments of the functional capacity of patients or have other restrictions regardless of patient presentation (i.e., otherwise healthy teenager with known underlying psychiatric condition who presents with suicidal ideation vs. a teenager who is presenting to the ED for the first time with altered mental status, psychosis, abnormal vital signs, etc.) and which may make more sense for adult populations with higher rates of medical comorbidities. This particular aspect of exclusionary criteria reflects the fact that these lists are made for adult patients, and not specifically targeted to the needs and challenges of the pediatric population.
Table 1: Exclusionary criteria based on Pre-existing or current medical condition

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Table 2: Exclusionary criteria based on required therapy

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Table 3: Exclusionary criteria based on laboratory values or ancillary testing

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Figure 1: Pediatric exclusionary criteria for pediatric psychiatric inpatient hospitalizations. CPK=Creatine Phosphokinase

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Our results suggest the criteria can be organized into three categories, based on similarities between requirements of the facilities listed. The first category, summarized on [Table 1], captures exclusionary criteria based on patient's preexisting or current medical condition and capabilities ranging from hypertensive urgency and recent stroke (two conditions not generally seen in this pediatric population) to pregnancy and acute alcohol intoxication. The second category, summarized in [Table 2], addresses administrative burdens that impact staffing requirements or require advanced equipment or training including patients that require respiratory isolation, tracheostomy care, etc. The third and final category depicted in [Table 3] and [Figure 1], details the laboratory and ancillary testing required by inpatient facilities before acceptance of the patient. We have numbered the facilities from 1-7 as we were unable to secure permission from each facility to publish their individual exclusionary criteria.

  Discussion Top

Visits for mental health complaints account for a significant portion of all ED encounters. The emergency physician's roles are essential in determining the patient's medical stability and suitability for inpatient hospitalization. ACEP's official stance, at least on adult psychiatric patients, is that routine laboratory testing is very low yield, costly, and generally not recommended.[17] This policy flies in the face of the “exclusionary criteria” required by inpatient treatment facilities. These criteria are the rules and requirements that must be met, even when not otherwise clinically indicated, before patients are accepted by inpatient psychiatric facilities.

As seen in [Table 1], psychiatric patients with complicated preexisting medical conditions are denied admission to many inpatient psychiatry treatment facilities. Any patient requiring intravenous medications or treatments are denied admission. In addition, patients with cognitive impairments, limitations, or disabilities including autism and intellectual disability are excluded from many inpatient psychiatric facilities though these conditions are highly associated with mental and behavioral disturbances. Perhaps most disturbingly, this patient subpopulation often requires 1:1 sitters and elopement precautions, yet are precluded from admission to all of the inpatient facilities in this city. The reason behind this exclusionary criterion is not explicitly stated, but in the authors' experience, it may be due to an inadequate staffing model. Thus, the facilities whose personnel have the most training to monitor children and adolescents with psychiatric and behavioral emergencies do not admit them.

These patients are then boarded in the ED until a suitable facility is located or treatment plan is developed. At our hospital, these patients are co-managed by the ED and emergency psychiatry department until an inpatient bed is available. Medications are given and may even be adjusted to stabilize the patient. The patient's condition is reviewed by our teams regularly to see if there is any change in their condition that would enable them to overcome the exclusionary criteria preventing inpatient admission. Yet, even though pharmacological management is provided in an attempt to mitigate ED boarding, an ED environment will never be able to provide the therapeutic milieu sought after in hospitalization. These patients typically have extremely long lengths of stay, in some cases, even spanning days or a week. This can have the effect of overwhelming staff and directly impacts patient safety (not only the safety of the individual patient as their care will be handed off multiple times during the course of their stay but also for the patients in the waiting room as the emergency room bed will be occupied until the patient can be transferred to another facility). This is also a significant burden to the patients' caregivers as parents are supposed to be present with their minor children and failure to stay may be viewed as abandonment.

Especially for patients with autistic spectrum disorders, intellectual disability, or other neurodevelopmental disorders, the sensory input and overload of the ED make the ED an unsuitable environment to stabilize the patient's neuropsychiatric and any coexisting medical condition. Moreover, many of these patients are already on complex medication regimens designed to control their behavior and symptoms. They may also be sensitive to new medications and can have paradoxical responses to the agents that most emergency providers are comfortable utilizing in the ED to stabilize acute psychiatric and behavioral emergencies, with a well-known example being paradoxical excitement to sedative-hypnotics.[18] This is neither in the patient's or provider's interest.

As [Table 3] and [Figure 1] demonstrate, there are no uniform criteria with respect to required laboratory testing. As a result, the inpatient facility that requires the broadest workup often dictates what tests the emergency physician will order to facilitate the medical clearance/assessment of the patient. A more minimalistic approach will require that the provider order additional tests depending on local facility bed availability. Such add-ons can serve to further delay patient stay in the ED and may result in repeated blood draws which can traumatize an already fragile pediatric patient. However, ordering all tests upfront increases costs and increases the chance of discovering a clinically insignificant abnormal result which could result in denied acceptance at psychiatric facilities. The breadth and necessity of ancillary tests are a bone of contention among interdisciplinary teams involved in pediatric psychiatry patient care in emergency settings.[19]

Zun et al. surveyed 507 EPs and 65 psychiatrists in Illinois regarding the use of ancillary testing in the medical clearance of adult psychiatric patients. The most commonly ordered tests included urine drug screens, alcohol levels, and complete blood counts. Of possible medical clearance tests, electroencephalograms, computed tomography scans, and lumbar punctures were least commonly ordered.[20]

In another study with data from 1082 pediatric psychiatric visits, screening laboratory examinations were ordered in 871 visits, and not one patient was diagnosed with a medical etiology for their psychiatric symptoms based on the results of the screening laboratory examinations alone.[21] Moreover, only one patient's disposition changed when she was admitted to a medical ward because of a positive pregnancy test. Twenty-five patients with noncontributory history and physical examinations had non-urgent management changes, such as treatment of anemia, based on their test results. The investigators recommended against routine testing with the exception of pregnancy tests for post-pubertal females (for medication management) and recommended that tests be ordered as indicated based on the patient's history and physical examination.

Santiago et al. reviewed visits from 210 pediatric ED patients and found that screening laboratories were of low yield because not one routinely ordered test altered acute patient management: with respect to the 54 patients who had nonmedically indicated laboratories done at the request of psychiatry for the purpose of admission or transfer, the only abnormal laboratories were one abnormal complete blood count, two abnormal transaminases, one positive urine drug screen, and one abnormal urinalysis.[22]

Although not specific to pediatric patients, an anonymous mail survey of 500 emergency physicians revealed that 35% of the respondents stated that laboratory testing of psychiatric patients was mandatory, regardless of patient presentation. Sixteen percent of the required testing was mandated by ED protocol while the remaining 84% was dictated either by the psychiatrist or psychiatric facility.[23] Few respondents of the survey believed that the testing was necessary or added clinical value. Another retrospective study analyzed patients presenting with psychiatric symptoms based on the International Classification of Diseases-9 codes and found that there was a large discrepancy from facility to facility in the number of laboratory tests used in the medical clearance of a patient.[24] One facility may order up to 4 times as many laboratory tests as another. The reason for this is likely multifactorial, reflecting the rising use of exclusionary criteria by psychiatric facilities, lack of traction in implementing ACEP's policy statement as a more widespread practice, and the provider to provider difference in knowledge regarding the literature involving medical clearance. Our review of exclusionary criteria in the Houston-Galveston Metro area shows similar variability in requirements.

There is room for the future development of policy and protocols in the realm of medical clearance of the psychiatric patient. For instance, the Massachusetts College of Emergency Physicians (MCEP) and the Massachusetts Psychiatric Society formed a joint task force to develop a consensus recommendation regarding obtaining urine toxicological screens in psychiatric patients presenting to the ED.[25] Change may need to occur initially on a statewide or regional basis before more widespread implementation. The MCEP and the Massachusetts Psychiatric Society joint task force may serve as a framework for drafting future guidelines. However, even the MCEP taskforce does not include patients under the age of 15 in their guidelines.

We have also identified patient populations that are currently not able to access needed inpatient psychiatric services. Although it is understandable that not all psychiatric inpatient facilities are equipped to care for patients with ongoing medical needs, frequently there is no acceptable disposition available for certain groups of patients. Patients with coexisting medical conditions frequently do not meet requirements for inpatient medical admission, cannot be safely discharged home, cannot be transferred to a psychiatric hospital, and are consequently board in the ED where they do not generally receive an appropriate level of treatment for their psychiatric illness. There is a serious need for units equipped for psychiatric patients with ongoing medical comorbidities where all issues can be treated simultaneously. This would likely require higher levels of reimbursement by insurance companies.

Other large groups of patients who currently have difficulty accessing needed psychiatric inpatients services are pediatric patients with intellectual disabilities and autism. These already vulnerable patients also frequently cannot be placed, do not receive necessary psychiatric care, and are boarded in EDs where lack of sleep, chaos, and lack of routines are likely to be further destabilizing. In short, there is a critical need to provide developmentally appropriate inpatient care to autistic and intellectually disabled children with severe behavioral problems and comorbid psychiatric conditions because even if an inpatient bed can be located, the specific needs of these patients may not be adequately served in general child and adolescent psychiatry wards.

  Conclusion Top

Psychiatric emergencies constitute a significant burden on the health-care system. Emergency physicians are often tasked with the initial assessment of the pediatric patient with psychiatric symptoms and are frequently asked to “medically clear” a patient for psychiatric inpatient care. Most psychiatric facilities employ exclusionary criteria requiring all patients to receive routine testing before admission. An evidence-informed change may need to come at the state and local level first. A future protocol based on prospective studies which represent a higher level of evidence would be ideal in driving future policy.

Emergency medicine, emergency psychiatry, and inpatient psychiatry each play a key role in the stabilization, treatment, and ultimate disposition of patients with behavioral emergencies, and until we develop interdisciplinary guidelines and consensus, patients and providers bear the consequences of an inherently unstable construct.

We agree with ACEP and the American Academy of Pediatrics (AAP) that pediatric behavioral and mental health emergencies are best managed by trained, interdisciplinary teams and applaud their commitment to advocating for adequate resources to treat pediatric psychiatric patients, developing mechanisms in the ED to address the specific needs of this patient population and promoting research and education in this area.[24] As a critical step in this process, we urge the ACEP, AAP, APA, and the American Academy of Emergency Psychiatry to adopt consensus guidelines for the medical clearance/assessment process for children and adolescents and to provide more specific guidance for uniform exclusionary criteria for inpatient hospitalization. Furthermore, these specialties together can advocate for the establishment of facilities with the capacity to treat the especially vulnerable groups of pediatric psychiatric patients, namely, patients with comorbid medical disorders, intellectual disability, and autism. As the number of pediatric patients diagnosed with mental health disorders increases, and the volume of patients diagnosed with autism, intellectual disabilities, and other neurodevelopmental disorders increases and ages, this patient population continues to experience significant difficulty obtaining the much needed inpatient psychiatric care for which outpatient psychiatric treatment and ED visits cannot adequately substitute.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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World Health Organization. Prevention of Suicidal Behaviours: A Task for All. Mental Health Action Plan 2013-2020; 2016. Avaialble from: http://www.who.int/mental_health/prevention/suicide/background/en/. [Last accessed on 2016 Aug 07].  Back to cited text no. 4
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Wharff EA, Ginnis KB, Ross AM, Blood EA. Predictors of psychiatric boarding in the pediatric emergency department: Implications for emergency care. Pediatr Emerg Care 2011;27:483-9.  Back to cited text no. 16
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Mancuso CE, Tanzi MG, Gabay M. Paradoxical reactions to benzodiazepines: Literature review and treatment options. Pharmacotherapy 2004;24:1177-85.  Back to cited text no. 18
Tucci V, Siever K, Matorin A, Moukaddam N. Down the rabbit hole: Emergency department medical clearance of patients with psychiatric or behavioral emergencies. Emerg Med Clin North Am 2015;33:721-37.  Back to cited text no. 19
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Donofrio JJ, Santillanes G, McCammack BD, Lam CN, Menchine MD, Kaji AH, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med 2014;63:666-75.e3.  Back to cited text no. 21
Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency department: Epidemiology, resource utilization, and complications. Pediatr Emerg Care 2006;22:85-9.  Back to cited text no. 22
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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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