‘Bundling’ Intervention Boosts Mental Health Care for Suicidal Kids in the ED

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A mother brings her daughter to the emergency department (ED) and says, “We need help. [My daughter] wants to kill herself.” Before the visit, the mother sought a therapist for her child but wound up on a waitlist.

The scenario plays out every single day in U.S. EDs, according to Kathleen Kiley, RN, senior staff nurse and clinical educator for emergency nursing at Boston Children’s Hospital, who spoke last week at Emergency Nursing 2021, an Emergency Nurses Association virtual meeting.

ED visits for suicidal ideation or suicide attempts by youth have risen by 500% from 2009 to 2019, said Kiley, who presented findings of an intervention implemented at Boston Children’s to address ED boarding times for kids presenting with behavioral health needs.

Suicide has become the second leading cause of death for children over 10 years of age, she said. In addition, one in six kids in the U.S. has been diagnosed with a mental health disorder.

Of course, the pandemic upended children’s normal routines, so “children are depressed, they’re dysregulated and disruptive,” Kiley said. To make matters worse, there are few outpatient community-based care options for children; behavioral health resources are often provided through the schools, and families lost access to those during school closures and community lockdowns, she explained.

The “families are just desperate and turn to emergency nurses for help because they see us as their safety net,” Kiley said.

ED boarding times — the time from admission order to ED departure — for pediatrics patients with behavioral health issues doubled from 2009 to 2019, according to the Pediatric Health Information System, a comparative pediatric database, and “extended stays and delays in definitive care that they encounter [in the ED] create stressors and problematic outcomes for children, families, and healthcare providers,” Kiley said.

Children who are ED boarding are not getting a lot of treatment, she noted. With their coping skills tested, “it all just starts to simmer,” she said. “Eventually it will boil over.”

The ‘Behavioral Bundle’

In 2018, Boston Children’s saw a threefold increase in adverse behavioral health events during times when the hospital was experiencing higher patient volumes. Kiley and colleagues developed and tested a quality improvement protocol to reduce the rates of adverse events (AEs) among children with behavioral health problems in the ED by 10% by December 2020.

Kiley told MedPage Today in a phone interview that AEs “could be something as basic as an observer not following safety protocols, or a patient becoming agitated and striking out at the nurse or observer. Or it might be that a medication is delivered incorrectly because the patient didn’t share the correct regimen.”

During a pre-intervention period, an interdisciplinary group of ED staff formed a task force that, after analyzing the hospital’s sentinel event reporting system, identified key drivers of events and formed working groups around each of those drivers. These included safe room entry, observant monitoring throughout the ED stay, accurate medication delivery, active psychiatry engagement, and personnel safety.

“Each of those groups created small iterative cycles of change,” she said, which were concrete actions that could be taken to reduce risk around different aspects of a patient’s stay. They named the intervention the “behavioral bundle.”

Kiley’s group also tracked other “process measures” such as:

  • Percentage of patients for whom a behavioral bundle was initiated at the start of care
  • Percentage nurse reporting that the bundle contained the information needed to care for the patient
  • A medication history completed by the nurse within 2 hours of patient’s arrival
  • Percentage of nurses reporting that the bundle was easy to use

The paperwork for the bundle is kept in a folder on the exam room door in an effort to standardize care, and includes the following key components:

  • Room checklist: Removing or securing environmental risk factors, such as trash cans, oxygen tanks, and extra chairs to decrease the risk of a patient using an item in the room for self harm. Staff are required to ensure that the patient’s room is “ligature resistant,” Kiley said.
  • Nurse task list: Search of the patient and the patient’s belongings; complete a medication history, provide 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 behavioral health “golden hour,” Kiley said. “It prioritizes safety for the patient and provides consistency for the nurses.”
  • Family education sheet: Outlines the ED psychiatry process and patient safety protocol; establishes a consistent set of expectations for families and staff.
  • Monitoring form: Provides a “snapshot” of the reason for the patient’s stay; what activities, behaviors, and even foods the patient is permitted, such as if the patient is allowed to take walks and whether the “constant observer” is a care companion or institutional security. Any restrictions that are updated twice daily by the hospital’s behavioral response team.
  • Coping skills form: Completed by the patients or by a caregiver in order to self-identify any triggers and/or identify ways to help to calm the patient.

Other tools are a schedule to give the patient’s stay structure; a “tip sheet” on environmental, behavioral, and communication strategies; and the evidence-based handoff I-PASS program to communicate any important information about an inpatient.

Phase II of the project began in January 2020 and included educating ED physicians, nurses, and other clinical and administrative staff about the bundle.

Drops in AEs

Kiley and colleagues surveyed the nursing staff 2 weeks after the intervention began. The nurses reported that they were pleased with the bundle; 9 months later, they said they continued to find value in the bundle. Kiley’s group found that medication history completion rates increased to more than 89% within 2 hours of ED arrival.

Kiley’s group targeted use of the bundle with 70% of patients and, by the end of the study period, they averaged about 79%.

They reported that the rate of AEs per 1,000 behavioral health visits fell from 1.8 per 1,000 pre-intervention to 0.5 per 1,000 visits post-intervention, which exceeded the project goal of a 10% reduction in AEs.

Kiley acknowledged that the reduction in AEs was an association and that the project did not show causation, as other unaccounted factors may have contributed to the bundle’s success. Project limitations included the fact that it was done at a single academic institution so the findings may not be generalizable. However, she stressed that the behavioral bundle framework is transferable.

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    Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow

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