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Adolescents in mental health crisis: the role of routine follow-up calls after emergency department visits
  1. S M Hopper1,2,
  2. I Pangestu3,
  3. J Cations4,
  4. C Stewart1,
  5. L N Sharwood1,2,
  6. F E Babl1,2,3
  1. 1Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia
  2. 2Murdoch Children's Research Institute, Melbourne, Victoria, Australia
  3. 3University of Melbourne, Melbourne, Victoria, Australia
  4. 4Psychiatric Liaison Service, Royal Children's Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Sandy M Hopper, Royal Children's Hospital, Parkville, VIC 3055, Australia; sandy.hopper{at}


To improve care of adolescents in mental health crisis, the role of routine follow-up calls in discharged patients with referral plans after emergency department (ED) presentation to a children's hospital was explored. Main outcome measure was patient attendance at referral sites. In 113 mental health patients with follow-up appointments, either patient/carers or corresponding referral services could be contacted. Median age was 14 years, 77% were girls, and most presentations were after self-harm/depression (61%). Eighty-three per cent (95% CI 75% to 90%) were compliant with the discharge plan without prompting from the ED staff. Fourteen per cent (95% CI 8% to 22%) did not comply after being called by ED staff, and only 3% (95% CI 1% to 7%) were persuaded to attend their outpatient care after being prompted by ED staff. Routine follow-up calls for adolescent mental health patients after ED care are not warranted in all settings.

  • Adolescent
  • mental health
  • emergency department
  • screening
  • emergency care systems
  • paediatrics

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Although emergency department (ED) management addresses the short-term needs of adolescents with mental health issues, ED visits do not allow for comprehensive assessment and ongoing care.1 2 Follow-up care by mental health services is frequently necessary,1–3 however many children with psychiatric problems are discharged from the ED with limited follow-up despite a high recurrence risk.2 4 A clear and comprehensible follow-up plan for further assessment and care should be ensured before they are discharged from ED,2 based on collaboration between EDs and mental health services.1 3 5

Adolescents have been viewed as difficult to engage and noncompliant, with subsequent community care compliance reported between 23% and 77%.2 6–8 We set out to determine if telephone follow-up was required to prompt and track attendance at referral sites after ED visits for mental health problems.


This study was undertaken at a large tertiary children's hospital ED in Melbourne, Australia. From July 2006 to February 2007, every patient (aged 8–18 years) with a presenting complaint related to a mental health issue was identified based on relevant triage or discharge codes. We excluded patients who were admitted to a psychiatric or medical inpatient unit as well as patients with drug and alcohol use with recreational intent. Patients discharged without a follow-up referral were also excluded. ED and mental health staff conducted routine follow-up telephone calls within 3–7 days postdischarge to ensure attendance at referral. In the first instance, a call was placed to the referral destination. If patients/carers had not arranged and attended the appointment, ED staff contacted the parent/carer to prompt attendance at the follow-up appointment.

The study was approved as an audit by the ethics committee at Royal Children's Hospital.


The study identified a total of 270 presentations for mental health issues during the 7-month study period. One hundred and forty-four patients were excluded (admitted, 67; recreational substance abuse only, 45; absconded, 8; no referral made, 21; came back to ED before follow-up appointment, 3). In 13 patients, the referral sites could not be contacted. We successfully contacted 113 patients/carers and referral destinations who represent the study group. Most of these patients were female (77%), arrived by private car (61%), had ATS triage categories one to three (51%) and received specialist mental health evaluations in the ED (79%). Most presented after self-harm, depression or suicidal ideation (61%), and most were referred to outpatient mental health services at discharge (61%). A range of other referral sites included other counselling services and general practitioners.

Of the 113 referred patients, 94 (83.1%; 95% confidence interval (CI) 75.0% to 89.5%) attended their follow-up appointment without prompting. Of the remaining 19 patients (17%), only three (2.6%; 95% CI 0.5% to 7.5%) were persuaded to attend as a result of the follow-up call. Sixteen patients (14.1%; 95% CI 8.3% to 21.9%) did not attend referral sites despite prompting.


The high baseline compliance with follow-up arrangements without prompting by ED staff was contrary to expectations and higher than previous reports.3 9 Comparisons with international compliance rates are problematic due to differences in patient demographics and in the organisation of healthcare systems.6 10

That follow-up calls were associated with a change in behaviour in only 3% of patients calls the resource-intensive process into question. Based on these findings, our ED has discontinued this practice.

It is disconcerting that 10% of referral destination sites could not be contacted by ED staff even after repeat telephone calls. It is advisable for EDs to provide a back-up contact telephone number to access hospital-based mental health services for discharged patients in the event that they are unable to contact referral sites.

Limitations include the short-term nature of our outcome measure (attendance at the referral site) and the exclusion of patients with ‘recreational’ drug use and admitted patients. It is difficult to generalise our findings to other EDs with different demographics, case mixtures, referral processes and accessibility.


The process of active follow-up in adolescents with ED mental health presentations may not be routinely warranted.



  • Competing interests None.

  • Ethics approval The study was approved as an audit by the ethics committee at Royal Children's Hospital, Melbourne, Australia.

  • Provenance and peer review Not commissioned; externally peer reviewed.