Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Somatic symptom and related disorders (SSRDs) are a group of diagnoses characterized by the presentation of one or more physical symptoms that are either inconsistent with physical disease based on a thorough medical evaluation or vastly disproportionate to findings on a thorough medical evaluation, and result in significant impairment. These symptoms are often significantly influenced by psychological factors including acute or chronic distress, as well as visceral hypersensitivity and habituation of maladaptive responses to somatic sensations. These conditions are common in pediatric medicine, accounting for up to 50% of primary care visits for abdominal pain, headache, and fatigue. There is a lack of a coordinated approach to SSRD care, often resulting in excessive and unnecessary healthcare utilization, miscommunications, missed opportunities to intervene, and considerable frustration from patients, families and providers.

Methods: There is limited information in the literature for how to provide SSRD care in practice and no current consensus guidelines for SSRD care in youth. At our institution, we convened a multidisciplinary group of providers, used LEAN methodology to assess problematic areas, including areas of inefficiency or disruption in work flow, gathered data from primary care providers statewide to inform understanding, and developed an evidence-based, institutional clinical practice guideline for management of SSRD care within the emergency department (ED) and inpatient setting. In addition, we have integrated education on SSRDs into our pediatric and psychiatric trainee curriculum.

Results: We will present the consensus-building process and multidisciplinary group formation used at our institution to develop standardized tools, resources, a clinical protocol and a clinical practice guideline. This includes a review of our value stream map as part of incorporating LEAN methodology in our process. We will review current evidence in SSRD practice, including data gathered from a statewide survey on practice. We will share our clinical protocol that outlines a detailed approach to suspect and confirm diagnoses of SSRD starting in the ED setting, as well as principles and contents from an interdisciplinary, hospital-wide clinical practice guideline with several associated clinical resources for practical application of the practice guideline and protocol.

Conclusion: Our institutional and statewide data align closely with existing evidence that indicates SSRDs are common, that providers, both medical and psychiatric, have little training or education on these conditions, that these conditions often present in emergent settings, and that patients and families often seek an overly physical conceptualization to their symptoms that is devoid of mental health involvement, which often leads to unnecessary and significant healthcare utilization. Initial results from our institutional approach, resulting in consensus-based practice guidelines, protocol and resources, suggest a model that can be used in ED and inpatient settings to address the needs of this pediatric population.