32 - A quality improvement initiative to reduce intramuscular medications for patients with agitation in a pediatric emergency department

Poster Number: 32
Publication Number: 32.406

Paul C. Mullan, Children's Hospital of The King's Daughters, Norfolk, VA, United States; Lauren Nielsen, Children's Hospital of The King's Daughters, Grafton, MA, United States; Robin M. Kelsey, CHKD, Norfolk, VA, United States; James M. Schmidt, Children's Hospital of The King's Daughters, Norfolk, VA, United States; Andrea D. Jennings, Children's Hospital of The King's Daughters, Norfolk, VA, United States; Amy M. Krupa, Children's Hospital of The King's Daughters, Norfolk, VA, United States; Mary M. Gleason, Children's Hospital of the King's Daughter and Eastern Virginia Medical School, Norfolk, VA, United States; Alice Mullinary, Children's Hospital of The King's Daughters, Virginia Beach, VA, United States; Karen K. Mitchell, Children's Hospital of The King’s Daughters/EVMS, Norfolk, VA, United States; Daniel B. Spencer, Children's Hospital of The King's Daughters, Norfolk, VA, United States

Background: An increasing number of children in our Emergency Department (ED) with mental health (MH) diagnoses present with significant agitation. The use of physical restraint (PR) or intramuscular medication for agitation (IMA) is associated with adverse patient and provider outcomes.

Objective: We aimed to decrease the baseline (3/2019-10/2020) rate of MH-related ED visits that required IMA from 1.52% to less than 1.14% (a decrease of 25%) within 12 months of project implementation.

Design/Methods: We included patients whose top 5 ED discharge diagnosis had a MH diagnostic code. IMA was considered if lorazepam, olanzapine, haloperidol, or diphenhydramine were given for agitation during the ED visit. IMA charts were reviewed by two investigators to exclude any medical (eg, allergy) cases. A proportion (p) chart and chi-square test were used to compare the baseline and intervention period IMA rates. A key driver diagram (Fig.1) was created and Plan-Do-Study-Act (PDSA) cycles implemented, including a care pathway (PDSA1: 11/2020), a post-event team debriefing tool (PDSA2: 5/2021), and online training for ED team members (PDSA3: 7/2021). All IMA doses ordered within a 60 minute time frame were considered a single IMA event.

Results: We had 3954 and 2761 patients in the baseline and intervention (11/2020-10/2021) period; 3 IMA patients were excluded. The intervention period (11/2020-10/2021) IMA rate decreased to 1.27% but was not significant (p=0.40) and no special cause variation detected (Fig.2). We have completed 69 post-event debriefings (median duration of 8 minutes) and 71 (86%) ED team members completed the online education. From 3/2019-10/2021, there were 150 IMA events over 96 ED visits; a total of 230 doses of IMA medications were given, including lorazepam (n=93; 40%), diphenhydramine (n=69; 30%), haloperidol (n=37; 16%), and olanzapine (n=31; 13%). The first IMA event occurred within a median of 2.9 hours (IQR 1.2, 7.6) after ED arrival. Thirty-one (32%) and 14 (15%) of the ED visits with an IMA event had >=2 and >=3 IMA events, respectively.Conclusion(s): We continue to work with multi-disciplinary input to achieve more significant decreases in our IMA rates. Future PDSA cycles include opening an adjacent 6-bed MH ED unit (1/2022) and a triage aggression screening tool. A data report on the ED PR rate is being built, and we aim to decrease PR rates as well.
Figure 1: Key Driver Diagram: ED Patients with Agitation or AggressionAbbreviations: APT (Aggression Prevention Team), CPI (Crisis Prevention Institute), DART (Days Away Restricted Time), ED (Emergency Department), ESI (Emergency Severity Index), MH (Mental Health), SMART (Specific Measurable Actionable Relevant Time-bound), SSQ (Suicide Screening Questionnaire)
Figure 2: Proportion of intramuscular medications for agitations in emergency department patients with a discharge diagnosis of a Mental Health ICD10 code in the Dx1 to Dx5 position.Figure Notes: Plan-Do-Study-Act (PDSA) 1=Agitation care pathway. PDSA2=Post-event team debriefing tool. PDSA3=Online educational tool to all emergency department team members. Center line of 1.52% is based on the first 20 months (3/2019 to 10/2020) of data.