Behavioral Health Issues Clinical Pathway — Emergency Department

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Related Pathways
Behavioral Health Disposition, Inpatient
Supporting Children with Challenging Behaviors Primary Care
Autism Screening, Primary Care

Presenting with Behavioral Health (BH) Concerns

Triage

Complete Behavioral Risk Assessment for all children and teens
Complete Ask Suicide-Screening Questions (ASQ) for children ≥ 8 yrs
Considerations for Patients ≥ 18 yrs with Primary BH Concerns

Identify Predominant Symptom:

Notify Social Work, Call for Safety Observer
Expedite to ED Room, use BH Rooms as able, place RED EPIC Security Bell

Suicide

≥ 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

Immediate Safety Observation
Use CHOP Staff Observer

Agitation

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

Immediate Safety Observation
Use CHOP Staff Observer

Use CHOP Staff Observer for all children even if:	Transferred from Inpatient Psychiatric Hospital BH complaint and in Law Enforcement Custody, notify Security
Indications for Safety Observation when other behavioral health concerns are present

BH Code Response

Medications
- Medication by Diagnosis, Agitation
- Medications, Medications for Violent Children
Manual Holds, Restraints
- Staff Roles
- Code Process
- Orders, Documentation

RN Actions

Search, Room Safety and Caretaker Guidance
- Orientation to ED room, change to gown
- Search person and belongings, secure belongings away
Behavioral Health Screen (BHS) for ≥ 12 yrs

History, Physical Examination, and BH Assessment

ED Medical Team
- Brief History, Physical, Development, Mental Status Exam (MSE)
- Altered Mental Status or Psychosis
- Medical Clearance
Social Work Assessment
- Columbia Suicide Screening as indicated
Psychiatry as indicated

Agitation Assessment

Team Huddle: Bedside Team, 1:1, SW
PRESS Quick Assessment
- Past History
- Reason for Agitation
- Environment
- Social
- Severity Assessment and Response

Agitation Treatment
Least Restrictive	Intermediate	Most Restrictive
Non-pharmacological Management Environmental modifications, distraction Consults Child Life, Social Work, Psychiatry, Security Communication Strategies	Medications	Manual Holds, Restraints

Ongoing Assessment

Medication side effects
Changes in care plan, shift changes, new behaviors

Disposition

Not Medically Cleared

Medically Cleared
Awaiting Inpatient Psychiatric Transfer

Discharge

Admit EDECU vs. Inpatient
Admission Location, Process
Inpatient Behavioral Health Discharge Disposition

EDECU Admit Guidelines
HOH Process
Search, Room Safety and Caretaker Guidance
‘All About Me’ Card
Daily Schedule, Team Responsibilities, Rounds
Prolonged EDECU Stays

Safety Plan when indicated
Ensure follow-up resources
Community Resources
Belongings with child
PCP communication

Posted: February 2013
Revised: June 2023

Authors:
- J. Esposito, MD;
- M. M'Farrej, MD;
- J. Lavelle, MD;
- E. Dalton, MD;
- A. Handa, MD;
- W. Geddings, MD;
- G. Andrade, MD;
- M. Wright, LCSW;
- K. White, LCSW;
- E. Steinmiller, RN;
- MK. Abbadessa, RN;
- K. Hummel, PharmD;
- G. Sharer, MSN;
- B. Nogales, RN;
- S. Zirbser;
- C. Roberts, CCLS;
- M. Deetscreek, CCLS;
- K. Osterhoudt, MD;

Editors: Clinical Pathways Team

Evidence

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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.

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Emergency Department Clinical Pathwayfor Behavioral Health Concerns

Evidence

Emergency Department Clinical Pathway
for Behavioral Health Concerns