The pandemic further strained the nation’s already overwhelmed pediatric behavioral health care system, posing additional challenges for children’s hospitals. Emergency department (ED) visits related to behavioral health following the pandemic’s onset in 2020 rose sharply compared to the same time period in 2019—increasing nearly 30% for children under 18 years old.
Children’s Health is a prime example of this trend. Although behavioral health issues comprised just over 3% of the hospital’s 2020 ED volume, those visits—tending to be higher acuity in COVID-19’s wake—consumed more than 25% of the department’s resources.
“The biggest problem for us was that the number of patients we were seeing during that year actually went down,” says Jamie Becker, Ph.D., ABPP, director of psychiatry at Children’s Health in Dallas, Texas. “That decline in volume, combined with the overwhelming number of resources allocated, told us that we really needed to do something different than what we were doing.”
Becker says it was a difficult task to determine where to begin working to improve those metrics, but her team began by focusing on two primary areas: standardizing patient documentation and making better use of technology.
Standardizing documentation for behavioral health patients
This was the “low-hanging fruit,” according to Becker. Previously, suicide assessments were found in various places of a patient’s report depending on who filed them, and templates for assessments had been personalized so often that there were few commonalities from report to report.
Becker and her team standardized all assessments to ensure a uniform process for reporting and identifying patient needs across all members of the care team. These include:
- Suicide assessment with clear delineation of elements.
- Template for initial assessment.
- Template for reassessments.
- Use of dropdown menus for efficiency.
- Embedded smart links for tracking.
- “Dot phrases” (note-keeping shortcuts) for anxiety, eating disorders, psychosis, aggression.
Leveraging technology for behavioral health patients
The Children’s Health team also found efficiencies could be gained by better leveraging available technology. “I would argue that the number-one change for our system came from engaging our information systems partners,” Becker says. “Without our information systems and analytic informatics, we would have gotten nowhere in this struggle.”
Those changes include:
- Behavioral health tracker. Real-time dashboard keeps tabs on ED patients and is accessible to the entire care team through the EMR—it replaced a dry-erase whiteboard in the unit. “This was a game changer,” Becker says.
- Computerized bed searches. Automation of a previously manual process to find space for behavioral health patients within the community. Frees up frontline clinicians to care for patients instead of having to work the phones to find patient beds.
- Suicide risk banner. Positive results of the Ask Suicide-Screening Questions (ASQ) screening tool automatically populate the patient’s EMR record. Notably, it saves time in the ED by allowing caregivers to move low-risk patients through the system more quickly without having to wait for a full psychiatric evaluation.
- Mental health transfer orders. Clarifies the process for discharging patients. “One of the biggest challenges we’ve had is resolution of medical clearance,” Becker says. “Someone who comes in with a broken arm can be seen for suicide ideation before they are fully medically cleared, but we don’t know when they’re cleared for transfer to discharge them from the system.”
- Automatic boarding protocol. Automatically pulls information from the EHR and visually summarizes whether patients are getting the care they need medically and psychiatrically in a 24-hour period. This was created when the hospital was struggling to keep up with all the information while both the ED and hospital were full.
Reduced ED boarding of behavioral health patients
Children’s Health’s improvements in documentation and technology utilization paid immediate dividends: ED boarding time for behavioral health patients decreased by nearly 36% by the end of 2022 due to the process modifications.
Meanwhile, Becker and her team—in collaboration with the entire organization—continue to strive for further efficiencies, including initiatives aimed at addressing staffing concerns. Among them: the hiring of non-clinical staff to ease administrative duties previously handled by practitioners and hiring psychiatric resource nurses who are available 24/7 to handle emergencies.
“We’ve managed to make significant strides on our goals, and it comes due to the massive executive-level commitment and support from the top down,” Becker says. “Most of our interventions were not owned only by the psychiatric team but were interdisciplinary, system-wide collaborations with buy-in from everyone.”