High – Risk Behavioral Health patient managment

by Sheena Noland

Coauthors: Sunni Yates, MADR, BSN, RN, CCRN-K Mary Hawes, RN, MSN, MBA Jamie Becker, PhD, ABPP Sheena Noland, BSN, MSN, APRN, FNP-C

Health Inequities

The mental health crisis shortage of psychiatric facilities in 2020, paired with a more than 51% increase in child and adolescent suicide attempts in 2021 and increased rates of depression, anxiety and eating disorders in youth have led to a surge of High-Risk Behavioral Health (HRBH) patients presenting to pediatric healthcare systems (CDC, Youth Risk Behavior Surveillance Survey (YRBSS), 2021). Per CDC, in 2020 there was a 31% increase in pediatric emergency room visits for mental health issues in patients ages 12-17 and 25% increase in ages 5-11 years of age. The aim of this project was to implement a method for early identification, communication, and intervention of HRBH patients upon entry to the healthcare system. Clinical staff reported not feeling equipped to care for HRBH patients at a large pediatric healthcare system. An innovated approach using the electronic health record (EHR) was implemented to increase staff awareness of past events and situational triggers to promote equitable care for HRBH patients. By bringing alerts, triggers, and comfort interventions to the most transparent section of the EHR we provided our staff with the greatest opportunity to intervene with an individualized treatment plan for the highest acuity HRBH patients.
To increase transparency and expedite knowledge transfer for all staff a multidisciplinary team consisting of nursing, informatics, psychiatry, and educators developed a behavioral health flag. The flag contains information including system alerts, behavioral triggers, interventions for crisis management, and a proactive plan for safety to help guide care across the patient encounters. Implementation began in October 2022 based on the need for continuity of care for two HRBH patients. A governing committee was created to perform a retrospective chart review from 2021 to present of patient/staff injury event files. Psychiatric resource nurses reviewed 249 patient charts involved in patient/staff events and escalated to the committee for further discussion and secondary review. Following committee confirmation, 38 flags were implemented in the patient EHR. Additionally, another 12 were added in real time by psychiatric resource nurses or patient care team escalation process to the psychiatric consult team.
Successful sustainability will include monthly committee system review and flag entry for identifying patients who meet flag criteria: events involving staff injury or those who have had multiple events requiring behavioral escalation team response. The system committee will include nursing, psychiatry, and physicians. Additional outcomes include increasing staff satisfaction and comfort with caring for HRBH patients and an increase in consultative services (proactive) approach to decrease emergency response needs (reactive).