A mother takes her daughter to the emergency room and says, “We need help. [My daughter] wants to kill himself. Before the visit, the mother sought a therapist for her child but found herself on a waiting list.
The storyline unfolds every day in America’s emergency rooms, according to Kathleen Kiley, a registered nurse and clinical emergency nursing educator at Boston Children’s Hospital, who spoke last week at Emergency nursing care 2021, a virtual meeting of the Association of Emergency Nurses.
Emergency room visits for suicidal ideation or suicide attempts among young people increased by 500% between 2009 and 2019, said Kiley, who presented the results of an intervention implemented at Boston Children’s to manage working hours. ” emergency boarding for children with behavioral health needs.
Suicide has become the second leading cause of death in children over 10, she said. Additionally, one in six children in the United States has been diagnosed with a mental health disorder.
Of course, the pandemic has disrupted children’s normal routines, so “kids are depressed, they’re deregulated and disruptive,” Kiley said. To make matters worse, there are few community ambulatory care options for children; Behavioral health resources are often provided by schools, and families have lost access to them during school closings and community lockdowns, she explained.
“Families are desperate and turn to emergency nurses for help because they see us as their safety net,” Kiley said.
Emergency room boarding time – the time between ordering admission and leaving the emergency room – for pediatric patients with behavioral health issues doubled from 2009 to 2019, according to the Pediatric Health Information System, a comparative pediatric database, and “the extended stays and delays in definitive care they encounter [in the ED] create stressors and problematic outcomes for children, families and health care providers, ”Kiley said.
Children in the emergency room do not receive much treatment, she noted. With their coping skills tested, “everything starts to simmer,” she said. “Eventually, it will overflow.”
The “Behavioral Bundle”
In 2018, Boston Children’s experienced a three-fold increase in behavioral health-related adverse events during times when the hospital saw higher patient volumes. Kiley and colleagues developed and tested a quality improvement protocol to reduce adverse event (AE) rates in children with behavioral health issues in emergency rooms by 10% by December 2020.
Kiley said MedPage today in a telephone interview, AEs “could be something as basic as an observer not following safety protocols, or a patient getting agitated and lashing out at the nurse or nurse. ‘observer. share the right diet. “
During a pre-intervention period, an interdisciplinary group of emergency department personnel formed a working group which, after analyzing the hospital’s sentinel event reporting system, identified the main factors of ‘events and formed working groups around each of these factors. These included entry into the security room, careful monitoring throughout the emergency room stay, accurate medication administration, active engagement in psychiatry, and staff safety.
“Each of these groups created small, iterative cycles of change,” she said, which were concrete actions that could be taken to reduce the risks associated with different aspects of a patient’s stay. They called the intervention the “behavioral package”.
Kiley’s group also followed other ‘process metrics’ such as:
- Percentage of patients for whom a behavioral package was initiated at the start of care
- Percentage of nurses reporting that the kit contained the information needed to care for the patient
- Medication history filled out by the nurse within 2 hours of patient arrival
- Percentage of nurses who said the bundle was easy to use
The documents for the package are kept in a file on the door of the examination room in an effort to standardize care, and include the following key elements:
- Room Checklist: Remove or secure environmental risk factors, such as garbage cans, oxygen tanks, and extra chairs to reduce the risk of a patient using an object in the room to self-harm. Staff are responsible for making sure the patient’s room is “resistant to ligatures,” Kiley said.
- List of nurse’s tasks: Search for the patient and his personal belongings; complete a medication history, provide the family with information on the hospital’s restraint policy; complete a patient safety form; discuss de-escalation techniques and coping strategies. This needs to be completed in the golden hour of behavioral health, Kiley said. “It prioritizes patient safety and ensures consistency for nurses. “
- Family Education Sheet: Describes the Emergency Department Psychiatry Process and Patient Safety Protocol; establishes a cohesive set of expectations for families and staff.
- Follow-up form: Provides a “snapshot” of the patient’s reason for stay; what activities, behaviors and even foods the patient is allowed, for example if the patient is allowed to walk and if the “constant observer” is a care companion or institutional security. Any restrictions updated twice daily by the hospital’s behavioral intervention team.
- Coping Capacity Form: Completed by patients or caregiver to identify triggers themselves and / or to identify ways to help calm the patient.
Other tools are a schedule to structure the patient’s stay; an “advice sheet” on environmental, behavioral and communication strategies; and evidence-based transfer I PASS program to communicate any important information about an inpatient.
Phase II of the project began in January 2020 and included training emergency department physicians, nurses, and other clinical and administrative staff on the package.
Decrease in AEs
Kiley and her colleagues interviewed nurses 2 weeks after the start of the procedure. Nurses said they were happy with the package; 9 months later they said they continue to find value in the bundle. Kiley’s group found that medical history completion rates increased to over 89% within 2 hours of arriving at the emergency room.
Kiley’s group targeted beam usage with 70% of patients, and at the end of the study period, they were on average around 79%.
They reported that the rate of AEs per 1,000 behavioral health visits declined from 1.8 per 1,000 pre-intervention to 0.5 per 1,000 post-intervention visits, exceeding the target for plan for a 10% reduction in AEs.
Kiley acknowledged that the reduction in AEs was an association and that the project did not show a causal link, as other factors not accounted for may have contributed to the overall success. Limitations of the project included the fact that it was carried out at a single academic institution, so the results may not be generalizable. However, she stressed that the behavioral grouping framework is transferable.