Improving Pediatric Emergency Department Lethal Means Safety Documentation Rates for Adolescents with Mental Health Concerns.
Lethal means safety counseling (LMSC) is recommended for children presenting to the emergency department (ED) for a mental health (MH) evaluation. Currently, no gold-standard guidelines exist for documenting LMSC in the ED.
This quality improvement project was conducted in the ED of a tertiary children's hospital. Baseline data were analyzed for access to any LMSC documentation (ALD) for "firearms/guns," "sharps," or "medication," and for complete LMSC documentation (CLD) if access to all 3 types was documented. The first intervention period added open-ended screening questions about access to lethal means to the MH-licensed clinical social worker note template. Intervention period 2 implemented an electronic health record "PowerForm" in Cerner PowerChart. We aimed to increase ALD and CLD to exceed 75% and 50%, respectively, during a 6-month period, with sustained success. Statistical process control p-charts with standardized special-cause rules were used to determine performance over time.
Baseline ALD and CLD rates were 3% and 1%, respectively. During intervention 1, the ALD and CLD rates increased to 81% and 68%, respectively, with special-cause variation noted for both rates. During intervention 2, ALD increased to 90%, but CLD rates did not change significantly (66%). For intervention 2, the documentation of firearm/gun access (90%) was higher than documentation of access to sharps (68%) or medication (69%).
We achieved a significant increase in ALD and CLD for MH evaluations in our ED. Lessons learned may generalize to other ED settings.
This quality improvement project was conducted in the ED of a tertiary children's hospital. Baseline data were analyzed for access to any LMSC documentation (ALD) for "firearms/guns," "sharps," or "medication," and for complete LMSC documentation (CLD) if access to all 3 types was documented. The first intervention period added open-ended screening questions about access to lethal means to the MH-licensed clinical social worker note template. Intervention period 2 implemented an electronic health record "PowerForm" in Cerner PowerChart. We aimed to increase ALD and CLD to exceed 75% and 50%, respectively, during a 6-month period, with sustained success. Statistical process control p-charts with standardized special-cause rules were used to determine performance over time.
Baseline ALD and CLD rates were 3% and 1%, respectively. During intervention 1, the ALD and CLD rates increased to 81% and 68%, respectively, with special-cause variation noted for both rates. During intervention 2, ALD increased to 90%, but CLD rates did not change significantly (66%). For intervention 2, the documentation of firearm/gun access (90%) was higher than documentation of access to sharps (68%) or medication (69%).
We achieved a significant increase in ALD and CLD for MH evaluations in our ED. Lessons learned may generalize to other ED settings.