Managing Minors Receiving Mental Health Treatment in the ED: What You Need to Know

Managing mental health patients who present to the Emergency Department is a challenge. But when your emergency mental health patient is also a minor, you must apply unique considerations to their care.

Here are eight vital facts you need to know about managing minors receiving mental health treatment in the ED.

Teen in Doctors Office

1. The provider may need to order limited visitation.

The LDH Office of Behavioral Health Rights of Minor Patients states that minor inpatients have a right to unimpeded visitation unless the provider orders otherwise.

But when a minor presents to the ED in a mental health crisis, visitation, and telephonic communication may be detrimental to their best interests. In those circumstances, the provider is responsible for documenting “sufficient cause” exists for the limitation of any of those rights.

It is possible to restrict visitation and correspondence with parents if the provider deems this to be in the child’s best interest. Minors may also communicate with an attorney at any time in whatever manner they choose.

In circumstances where the patient’s rights are restricted in any manner, the Rights of Minor Patients state that “the minors’ legal counsel and next of kin or responsible party, must be notified in writing of any restrictions and reasons.”

Facilities must implement policies and procedures related to patient visitation and communication with minors while they reside in the ED under a protective order. When permitting visitors, take precautions such as conducting a security wand inspection before entry to prevent contraband from passing to the patient.

2. Parents/Legal Representatives of minors may access medical records.

According to the U.S. Department of Health and Human Services Office for Civil Rights on HIPAA, parents and a minor’s representative may access information about their minor’s mental health treatment. Healthcare providers may decide to limit information shared with the parent or personal representative only if there are concerns about parental abuse, neglect, or endangerment.

Louisiana does not currently allow children to consent to mental healthcare. HIPAA considers psychotherapy notes privileged information, and they do not have to be shared because they are not considered part of the legal medical record.

3. Autism with intellectual disabilities doubles the risk of suicide.

Research shows autistic patients with intellectual disabilities are at higher risk for suicide attempts and deaths by suicide. Bullying, underemployment, and higher rates of mental illness contribute to the risk.

Safety is the priority when caring for these individuals — assess patients and their belongings for contraband and inspect the environment for potential risks upon entry into your facility. The staff should perform a suicide risk screening to identify active signs and symptoms of potential risk of self-harm. The physician should evaluate to determine if the patient requires inpatient hospitalization.

Staff trained in de-escalating and managing aggressive behavior should observe, communicate, and support the patient. As with any other patient, a safe environment should be provided, the patient should be educated on their diagnosis and medications, and resources should be provided upon discharge to promote a healthy lifestyle.

4. Restraint and seclusion rules apply.

Providers must document clinically justifiable reasons for implementing restraints or seclusion for cases when less restrictive measures fail or when they are necessary to prevent a patient from physically injuring themselves or others. The authority to institute seclusion or physical restraint requires a provider order, and the order must be renewed every twelve hours.

At the 24th hour, the provider should re-examine the patient and certify that continued restraint or seclusion is necessary.

The parent, tutor, or caretaker shall be notified by the 26th hour.

Hospital policies and procedures should be in place to observe the patient every 15 minutes or more frequently depending upon the physician’s order and provide for the patient's needs during this time. A patient’s needs include food, water, bathing, motion, and restroom use.

Without an order for seclusion, the staff may place a patient alone in a room for no more than 30 minutes or three hours in a 24-hour period. You may only utilize this period as part of a written treatment plan. Staff must never initiate chemical or physical restraints to punish or discipline a patient or as a convenience for staff.

5. Patients may or may not have access to their belongings.

Minors are allowed to wear their clothing and obtain personal possessions unless deemed medically inappropriate by the attending provider. Your facility must provide a form of clothing and toiletries if the patient does not have either.

Facility policies on this issue should include the general management of personal belongings such as logging personal items in the patient record, securing them, and methods for discarding contraband and illegal substances.

6. Use the PEC form that applies to minors.

The Physician's Emergency Certificate, or PEC, is required for all patients needing immediate psychiatric treatment in a facility on the basis that the patient is a danger to themselves or others, gravely disabled, or otherwise at risk related to substance abuse. Once a qualified medical provider initiates the PEC, your facility is authorized to detain a patient for 72 hours.

There is a specific PEC form required to commit a juvenile to a treatment center. The attending qualified medical provider must personally assess the patient and thoroughly complete the document for it to be valid. Minors can seek treatment if they are a danger to themselves or the safety of one's health is at stake.

7. Patient portal access is available to parents or guardians of minors with behavioral health issues.

In the last few years, patient portal usage has increased because portals can effectively provide access to messaging, appointment scheduling, diagnosis, medical regime, and lab results.

Sharing electronic patient health information of a minor may take place with the patient's parents or legal representative. Educate the patient and family on the use of the portal and who has access to this function. Since secure messaging is available, patients must be advised that the qualified medical provider may not necessarily provide an immediate response and is allowed two days to respond.

Maintaining confidentiality is of utmost importance. Adolescents under 18 can seek treatment related to reproduction, mental health, or substance abuse without parental consent.

In some cases, proxy access can be granted to access a patient’s electronic health information via the patient portal. Proxy access includes authorization of someone other than the patient’s parent or legal representative to access the medical record such as another provider, home health care staff, or another family member. Proxy access may be granted to limited information in the medical record or full access. Proxy access can help improve the continuity of care and follow-up post-discharge. Consent must be given by the patient for proxy access.

Your facility should determine and institute appropriate policies regarding access to patient information from your portal.

8. Telepsychiatry can be used for evaluation.

Telemedicine is the remote treatment of patients by using technology. Telepsychiatry enables the use of psychiatric evaluations and care for behavioral health patients. When a patient presents to your ED with a behavioral emergency and no psychiatrist on staff, telepsychiatry can be available.

It is crucial to provide specific training to staff in the proper use of telemedicine for the delivery of mental health care. Privacy and information sharing are factors to consider during the service along with access to patient health information.

Preparation Is Key

The management of mental health patients in the Emergency Department is challenging on its own. Adding minor patients who need mental health treatment complicates the scenario even further.

However, training staff on the key differences between minor and adult behavioral health patients, ensuring that the proper documentation is available to your team, and following your facility’s protocols for managing mental health patients are vital steps to establishing a proper environment of care in your facility’s ED.

Want more behavioral health resources? Our Behavioral Health Toolkit has materials intended to help facilities that treat adult and minor behavioral health patients, including care best practices, screenings, environment of care assessments, and more.