# Prior Out-of-Home Placement and Length of Stay Among Youths Receiving Mental Health Services in the ED

## TL;DR

Youths with a history of foster care spend more time in the ED and are more likely to be restrained during mental health crises.

## Contribution

This study identifies a link between out-of-home placement history and increased ED length of stay and restraint use in youths.

## Key findings

- Youths with OOHP history spent 24% more time in the ED compared to those without OOHP.
- OOHP patients had 2.05 times higher odds of physical restraint and 2.15 times higher odds of pharmacologic restraint.
- The study highlights the need for trauma-informed care for youths with OOHP history in emergency settings.

## Abstract

Is history of out-of-home placement (OOHP) associated with length of stay or use of physical or pharmacologic restraints among youths receiving mental health care in the emergency department?

In this cross-sectional study of 1572 care encounters among 1119 patients, those with history of OOHP placement (328 encounters) spent approximately 24% more time in the ED vs those without history of OOHP. These patients also had higher odds of receiving physical or pharmacologic restraints for agitation.

The findings of this study highlight the need for specialized, culturally sensitive, and trauma-informed services in psychiatric emergency settings for youths with a history of OOHP.

This cross-sectional study evaluates whether youth history of out-of-home placement (OOHP), ie, foster care, is associated with length of stay among children and adolescents who receive mental health care at an emergency department (ED).

Youth mental health crises have been increasing over the last decade, and there is an urgent need for clinicians to be more knowledgeable about patients with high emergency department (ED) utilization. Several disparities in ED utilization and outcomes have already been identified; however, little data exist on disparities affecting youths with histories of out-of-home placement (OOHP).

To explore whether history of OOHP is associated with increased length of stay among child and adolescent patients who present to the emergency department with psychiatric symptoms.

This retrospective, electronic health record (EHR)–based, cross-sectional study included patients aged 17 years or younger with a child and adolescent psychiatric consultation placed in the Mayo Clinic Rochester ED between January 1, 2021, and June 30, 2024. The Mayo Clinic Rochester is a tertiary referral center that serves as a regional hub for both primary and specialized psychiatric care.

The primary outcome was the length of stay in the ED. Secondary outcomes were use of physical and pharmacological restraint. Associations between OOHP and length of stay were examined via linear mixed-effects regression models with length of stay log transformed.

Of the 1572 care encounters (median [IQR] age, 14,9 [13.3-16.3] years) among 1119 unique patients, there were 1244 with no history of OOHP and 328 with history of OOHP. Among the OOHP group, 158 (48%) were male and 170 (52%) female; 11 (4%) American Indian or Alaska Native, 7 (2%) Asian, 49 (16%) Black, 43 (14%) Hispanic, and 222 (71%) White. Among the 1244 encounters without OOHP, 820 (66%) were among female patients and 423 (34%) male; 21 (2%) American Indian or Alaska Native, 47 (4%) Asian, 121 (10%) Black, 125 (10%) Hispanic, and 971 (80%) White. Children and adolescents with history of OOHP were observed to spend 24% (95% CI, 12%-36%) more time in the ED even when adjusting for age at admission, sex, insurance, number of prior diagnoses, presenting concerns, and reasons for prolonged boarding (P = .004). Children and adolescents with history of OOHP had 2.05 (95% CI, 1.69-2.48) higher odds of being physically restrained (P < .001) and 2.15 (95% CI, 1.79-2.58) higher odds of receiving pharmacologic restraints (P < .001) while in the ED.

In this cross-sectional study of 1572 care encounters among 1119 patients, history of OOHP was associated with longer lengths of stay in the emergency department for children and adolescents who presented for mental health concerns. The findings highlight the need for further research on ways to mitigate the risk of extended emergency department stays for children with OOHP.