Behavioral Health Concerns Clinical Pathway – Emergency Department

EMCP Guidance

Accepting Children with BH Concerns
- Notify Flow if medically cleared and not eligible for EDECU
Cedar Transfers
- HUP Cedar
- Transferring CHOP Cedar Patients to PHL
- Cedar Transfer Checklist
- Process for EDECU Direct Admit

Child/Adolescent presenting with Behavioral Health (BH) Concerns

ED Triage

Complete Behavioral Risk Assessment for all children
Complete Ask Suicide-Screening Questions (ASQ) for child ≥ 8 yrs
Notify Social Work (SW), call for CHOP Safety Observer
- Suicide, agitation, transferred from IP Psychiatric Hospital, High-Risk Safety Alert
- SW notifies Psych for arrivals with 302
BH RN Standing Order as indicated
Enter RED Epic Security Bell
Notify Security and assign CHOP Safety Observer if with law enforcement

Triage Considerations for Primary BH Concerns

Identify Predominant Symptom

Suicide

Agitation

≥ 8 yrs
- ASQ: positive or child refuses ASQ
All Ages
- Active suicidal ideation or attempt present
- Parent/guardian report SI, or attempt in the last month

Active physical aggression to self, others, property
Active verbal aggression

Immediate Safety Observation

Suicide Prevention Bundle
Aggression Prevention Bundle
Review Behavior Safety Alert
Expedite to Room

Agitation/Aggression Team Huddle

Bedside Team, BHC Charge
Consult SW and Psych early
PRESS Quick Assessment
- Past History
- Reason for Agitation
- Environment
- Social
- Severity Assessment and Response

Agitation Treatment
Least Restrictive
Non-Pharmacological Management Environmental modifications, distraction Consults Child Life, SW, Psychiatry, Security Communication Strategies
Intermediate Restrictive
Medications
Most Restrictive
BH Code Response Manual holds, restraints Orders, Documentation

ED Team Assessment

RN Actions
- Orientation to room, change into gown
- Search, Room Safety and Caregiver Guidance
- Review BH Utilization Alert
- Behavioral Health Screen (BHS) for ≥ 12 yrs
History and Physical
- Medical history, behavioral history, current treatment
- Review Differential Diagnosis for Altered Mental Status, Psychosis
  - Consult Psychiatry if concern for Psychosis, Catatonia, medication effects
- Review ASQ, BHS and BH Utilization Tool
- Complete Medical Clearance
  - SW assessment may begin if child can participate
Contact SW Early for Mental Health Assessment if:
- +ASQ or +BHS for current suicide even if denies during interview
- Severe Depression on BHS
- Safety Concerns identified during interview
- Risk and Protective Factors and Red Flags for suicide

Mental and Behavioral Health Assessment

Social Work
- Columbia Suicide Screening as indicated
- Review with PEM attending
- Indications for Psychiatry consult after SW

Determining Disposition

ED, SW, Psychiatry review risk determination and disposition planning
Communication via EPIC chat, in-person or phone conversation

Discharge

Not Medically Cleared

Medically Cleared
201/302 Signed and Awaiting IP Psych Admit

Medically Cleared
201/302 Not Signed

Safety Plan as indicated
Ensure follow-up resources
Community Resources
Return belongings with child

Admit EDECU vs. Inpatient
Ensure
- Home medications
- Agitation plan

Admit Process if Prolonged ED stay > 48 hr Anticipated
- Admit EDECU if eligible
- Review MBU Admission Procedure
- General Peds or Adolescent
  - Contact PSPF, NSPF for GP or Adolescent
- BH High Occupancy Hold Orders
  - Complete if long wait time to bed assignment
  - Ensure
    - Home medications, agitation plan
    - Bed order
    - Continue BH bundle care
    - Daily SW, Psychiatry care

Admit EDECU if eligible
- SW and Psychiatry re-assesses in a.m.
Discharge or
Admit Process if Prolonged ED stay > 48 hr Anticipated

Posted: February 2013
Last Revised: August 2026
Authors:
- J. Esposito, MD
- M. M'Farrej, MD
- J. Lavelle, MD
- M. Wright, LCSW
- S. Bamford, LCSW
- E. Steinmiller, RN
- MK. Abbadessa, ACCNS-P
- G. Sharer, MSN
- S. Zirbser, BA
- M. Deetscreek, CCLS
- B. Ketabchi, MD
- A. Brundage, CRNP
- L. Lenehan, CRNP
- T. Chen, MD
- P. Lee, MD
- C. Streater, LCSW
- E. Camac, RN
- B. Pagliaro, RN
- B. Kovaks, BA
- S. Carter, BA
- L. Walsh, PharmD
Editors: Clinical Pathways Team

Evidence

CHOP Program

Podcast

PEM Podcast, Mental Health Emergencies

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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