Fellow: Kate Kyler, MD | Children’s Mercy Kansas City
Article: Noelck M, Velazquez-Campbell M, Austin JP. A Quality Improvement Initiative to Reduce Safety Events Among Adolescents Hospitalized After a Suicide Attempt. Hospital Pediatrics. 2019;9(5):365-372. doi:10.1542/hpeds.2018-0218
Summary: This article is a quality improvement (QI) study aimed at improving the rates of serious safety events (SSEs) in children hospitalized for medical stabilization following self-harm or suicidal ideation prior to transfer to an inpatient psychiatric care facility. The authors acknowledge the increasing frequency of these types of hospitalizations occurring across the country as a result of increasing rates of adolescent mental health disorders coupled with limited mental health care resources. Their QI initiative included several process measures to improve rates of SSEs (i.e. elopement, self-harm, harm of others), including: development of a behavioral health safety protocol (including creation of a new order set), standardization of care surrounding these patients (e.g. safety search of belongings, use of standard patient handoff), and implementation of a daily safety huddle to improve communication among all team members. Their primary outcome measure was rate of SSEs per 100 patient days. Over the course of their QI study (January 2017 – June 2018), the rate of SSEs decreased from 2.7 events per 100 patient days in the pre-implementation period to 0.17 events per 100 patient days in the post-implementation period. They concluded that use of QI methodology to improve safety of teens hospitalized after a suicide attempt can lead to substantial and sustained reductions in SSEs.
What are the key strengths of the article? This study was performed at a pediatric institution highly motivated to enact change for children hospitalized following a suicide attempt after experiencing a few sentinel safety events. The study’s quality improvement design worked to provide structured interventions to quickly improve the safety of care provided to this growing population of children. This study is one of the first to report improvements in SSEs during hospitalizations of this type as a result of standardization of care. The alterations in process were often incorporated directly into workflow by way of the electronic health record (e.g. order sets, checklist documentation for nursing staff to complete). They also included some balancing measures in their analysis, such as patient behavioral escalations triggered by protocol restrictions (e.g. social media restrictions).
Are there any limitations or flaws in the article? Because of a lack of prior published literature on this topic, the authors selected Key Drivers and Interventions based on the study institution’s own root cause analyses results, expert opinion, and experiences of the care team members. Additionally, while the rates of hospitalization following suicide attempt are increasing, the overall SSE rate was rather low. The sample size was adequate to address the questions asked, but extension of these methodologies to other pediatric centers around the country would improve generalizability of the results. The authors also acknowledge that SSEs may not be consistently documented within the medical chart.
What is the major takeaway message? A multi-faceted and multidisciplinary approach to standardizing care for children hospitalized following suicide attempt may be an effective way to decrease the frequency of serious safety events during their stay.
Describe how this article should impact our practice: I chose this article because my hospital has also experienced these types of hospitalizations more frequently and has experienced more elopements and behavioral escalations requiring immediate intervention from the nursing, medical, social work and/or security teams. While we have implemented a standardized practice for responses to these acute events, standardization of practice from the moment of admission has not been attempted. I believe the interventions employed in this study improve communication among all team members and the patient/family unit, and this led to the decrease in SSEs. These types of interventions may be very useful in children’s hospitals around the country as we continue to grapple with a national pediatric mental health crisis.
Article: Noelck M, Velazquez-Campbell M, Austin JP. A Quality Improvement Initiative to Reduce Safety Events Among Adolescents Hospitalized After a Suicide Attempt. Hospital Pediatrics. 2019;9(5):365-372. doi:10.1542/hpeds.2018-0218
Summary: This article is a quality improvement (QI) study aimed at improving the rates of serious safety events (SSEs) in children hospitalized for medical stabilization following self-harm or suicidal ideation prior to transfer to an inpatient psychiatric care facility. The authors acknowledge the increasing frequency of these types of hospitalizations occurring across the country as a result of increasing rates of adolescent mental health disorders coupled with limited mental health care resources. Their QI initiative included several process measures to improve rates of SSEs (i.e. elopement, self-harm, harm of others), including: development of a behavioral health safety protocol (including creation of a new order set), standardization of care surrounding these patients (e.g. safety search of belongings, use of standard patient handoff), and implementation of a daily safety huddle to improve communication among all team members. Their primary outcome measure was rate of SSEs per 100 patient days. Over the course of their QI study (January 2017 – June 2018), the rate of SSEs decreased from 2.7 events per 100 patient days in the pre-implementation period to 0.17 events per 100 patient days in the post-implementation period. They concluded that use of QI methodology to improve safety of teens hospitalized after a suicide attempt can lead to substantial and sustained reductions in SSEs.
What are the key strengths of the article? This study was performed at a pediatric institution highly motivated to enact change for children hospitalized following a suicide attempt after experiencing a few sentinel safety events. The study’s quality improvement design worked to provide structured interventions to quickly improve the safety of care provided to this growing population of children. This study is one of the first to report improvements in SSEs during hospitalizations of this type as a result of standardization of care. The alterations in process were often incorporated directly into workflow by way of the electronic health record (e.g. order sets, checklist documentation for nursing staff to complete). They also included some balancing measures in their analysis, such as patient behavioral escalations triggered by protocol restrictions (e.g. social media restrictions).
Are there any limitations or flaws in the article? Because of a lack of prior published literature on this topic, the authors selected Key Drivers and Interventions based on the study institution’s own root cause analyses results, expert opinion, and experiences of the care team members. Additionally, while the rates of hospitalization following suicide attempt are increasing, the overall SSE rate was rather low. The sample size was adequate to address the questions asked, but extension of these methodologies to other pediatric centers around the country would improve generalizability of the results. The authors also acknowledge that SSEs may not be consistently documented within the medical chart.
What is the major takeaway message? A multi-faceted and multidisciplinary approach to standardizing care for children hospitalized following suicide attempt may be an effective way to decrease the frequency of serious safety events during their stay.
Describe how this article should impact our practice: I chose this article because my hospital has also experienced these types of hospitalizations more frequently and has experienced more elopements and behavioral escalations requiring immediate intervention from the nursing, medical, social work and/or security teams. While we have implemented a standardized practice for responses to these acute events, standardization of practice from the moment of admission has not been attempted. I believe the interventions employed in this study improve communication among all team members and the patient/family unit, and this led to the decrease in SSEs. These types of interventions may be very useful in children’s hospitals around the country as we continue to grapple with a national pediatric mental health crisis.