Behavioral Health Issues Clinical Pathway — Emergency Department

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

ED Patients with Behavioral Health Concerns

All Patients:
Behavioral Risk Assessment to determine interventions to maintain safety
Patients ≥ 10 yrs:
Complete Ask Suicide-Screening Questions (ASQ)

Mood/Behavior	Risk Level	≥ 10 years of age	< 10 years of age	Action
All suicide risk levels and aggression: Page Social Work on call Place RED EPIC Security Flag Expedite to ED Room, use BH Rooms as able
Suicide	High	ASQ: Yes to questions 3, 4, or 5 Patient refuses ASQ Active suicidal ideation or attempt Parent/guardian reported suicidal ideation or attempt within past week	Active suicidal ideation or attempt Parent/guardian reported suicidal ideation or attempt within past week	Immediate Visual 1:1 with CHOP Staff Observer Visual & Arms-Length 1:1 as indicated Page Psychiatry early if intent unclear Notify Team Attending
	Moderate	ASQ: Yes to questions 1 or 2	History of suicidal ideation or self-harm in the last month	Immediate Visual 1:1 with CHOP Staff Observer or Appropriate Adult Visitor (AAV)
	Low	ASQ: No to all questions	No history for suicidal ideation or self-harm	Immediate Visual 1:1 with AAV or CHOP Staff Observer
Aggression	High	Active physical aggression towards self, others or property Active verbal aggression		Immediate Visual 1:1 with CHOP Staff Observer Notify Security and Team Attending
Aggression	Moderate	Calm but history of aggressive behavior		Review 1:1 need
Patients presenting with other Behavioral Health Concerns may need 1:1 Observation and other Safety Practices Patients coming from an Inpatient Psychiatric Facility: perform BH Triage Screen in all & ASQ if > 10 years; use CHOP Staff Observer regardless of screen result Patients coming from Law Enforcement Custody: perform BH Triage Screen in all & ASQ if > 10 years; use CHOP Staff Observer for positive screens; notify Security and NOL of patient arrival

Other Considerations
- Columbia Suicide Screening
- Psych Tech Role, Responsibilities
- Voluntary/Involuntary Hospitalization
- COVID Considerations
- Forensic Patient
- Discharge for the Forensic Patient
- HOH Process

RN Actions, Documentation, and Orientation to ED Room
- Indications for 1:1
- Patient, Room Safety and Caretaker Guidance
  - Change to gown
  - Search person & belongings
  - Store belongings
- Caretaker Guidance for ED and EDECU
  - Review belongings
  - AAV expectations
- Documentation
- Behavioral Health Screen Eligibility, Follow-up

De-escalation Strategies
- Child Life
Medications
- Anxiolysis
- Aggression
Restraints
- Review Checklist
- Ensure Order
- Face to Face Evaluation
- Monitoring
- Documentation

Brief History, Physical, Development, MSE
- Initiate 1:1 as indicated and place order
Review Differential Diagnosis
Further Diagnostic Testing
Medical Clearance

Disposition

Inpatient Medical Admission

EDECU, Awaiting Inpatient Psychiatric Transfer

Inpatient Psychiatric Admission

Discharge

Requires Medical Care
Not Eligible for EDECU

EDECU Admit Guidelines
Patient, Room Safety and Caretaker Guidance
‘All About Me’ Card
Daily Schedule, Team Responsibilities, Rounds

Ensure 201 or 302
Transport Form Signed by ED
- Attending
Ensure Belongings with Patient
Child Life and Team Prepares
- Patient for Transfer
1:1 Observation

Safety Plan
Partial Program
Outpatient Referral
Community Resources
Ensure Belongings with Patient

Posted: February 2013
Revised: July 2015, November 2016, February 2018, April 2018, October 2018, February 2021, March 2021
Authors: J. Lavelle, MD; M. M'Farrej, MD; J. Esposito, MD; A. Jhonsa, MD; E. Perry, MSW; K. White, MSW; E. Steinmiller, RN; A. Felix, CRNP; K. Crescenzo, RN; MK. Abbadessa, RN, A. Fu, MD, C. Jacobstein, MD, K. Osterhoudt, MD; E. Friedlaender, MD

Evidence

Community Resources

Behavioral Health Referral Page
Youth and Family Response and Recovery Program at Penn
Call: 215-829-5467 or email: youthtrauma@uphs.upenn.edu

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.

Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Behavioral Health Concerns

Evidence

Community Resources