Developing a Pediatric Emergency Behavioral Health Acuity Assessment

Aim: : The national pediatric behavioral health crisis with subsequent increases in emergency department (ED) mental health visits has changed ED nursing (RN) practice. In the ED, children with behavioral health issues have dynamic acuity levels. Acuity assessment allows nurses to determine the level of severity of patients and helps identify needed resources and interventions. There are no comprehensive evidence-based tools that support ED nursing acuity assessment. The aim of this quality improvement project was to use the plan-do-study-act (PDSA) model to develop a novel, collaborative, interprofessional approach to design the emergency behavioral health acuity assessment tool (EBHAT) for pediatric behavioral health patients.

Framework:: The PDSA framework guided project design and implementation.

Setting:: The setting was a 47-bed urban Level 1 Pediatric Trauma Center in an academic, free-standing, non-profit, Magnet-designated 187-bed teaching hospital the Northeast.

Stakeholder Team:: Stakeholders included the ED Nurse Manager and Medical Director of ED Behavioral Health Services (project co-leads) that oversaw the entire project. The Behavioral Health Nurse Team Lead supported tool development, testing, education, and roll-out. Social Work, Psychology, Psychiatry, Clinical ED RNs, and Advance Practice Providers gave feedback and suggestions for changes to the tool throughout PDSA cycles. The Nurse Scientist provided evidence, project design, and data analysis support. The Director of Injury Prevention Center worked on conceptualization and grant submission. The Research Associate (project manager) supported grant management and project logistics.

Methods: : This project aimed to design and implement an ED nursing acuity assessment tool for behavioral health. Plan: the project team reviewed current evidence, available tools, and drafted tool design. Grant funding was obtained. Available pediatric and adult acuity assessments provided the framework for the EBHAT. Stakeholder input was incorporated. Do: EBHAT was tested in paper-form. Study: Feedback from RNs and staff were obtained. Act: the EBHAT was modified and re-trialed. Subsequent PDSA cycles included implementing modifications, feedback, and EBHAT revisions to frontline staff. EBHAT was added to EPIC in August 2021. PDSA cycles continued; RNs incorporated EBHAT into workflows. Project outcomes included: a behavioral health acuity dashboard, restraint use, and acuity levels. Descriptive statistics and comparative analyses were planned.

Outcomes:: Since implementation, a dashboard with real-time capture of ED behavioral health patients, acuity levels, and resource use was executed and informed staffing and resource decisions. From 2021 to 2022, restraint episodes decreased by 22.7%. August 2021 to August 2022 the average number of patients per shift with high acuity was 0.75, moderate acuity was 8.93, and low acuity was 12.6. The EBHAT was fully integrated into ED nursing care of behavioral health patients. Use was expanded to medical patients who the RN suspected had a mental health concern.

Implications:: This novel tool provided improved insight into the acuity of pediatric patients presenting with behavioral health concerns and allowed for better outcomes and resource utilization. The PDSA framework guided development and implementation of a new tool for pediatric ED RNs to guide and support care in this special patient population. Future studies are planned to look at patient indicators and the predictive value of the EBHAT.