Improving Pediatric Emergency Department Lethal Means Safety Documentation Rates for Adolescents with Mental Health...

Lethal means safety counseling (LMSC) is recommended for children presenting to the emergency department (ED) for a mental health (MH) evaluation. Currently, no gold-standard guidelines exist for documenting LMSC in the ED.

This quality improvement project was conducted in the ED of a tertiary children's hospital. Baseline data were analyzed for access to any LMSC documentation (ALD) for "firearms/guns," "sharps," or "medication," and for complete LMSC documentation (CLD) if access to all 3 types was documented. The first intervention period added open-ended screening questions about access to lethal means to the MH-licensed clinical social worker note template. Intervention period 2 implemented an electronic health record "PowerForm" in Cerner PowerChart. We aimed to increase ALD and CLD to exceed 75% and 50%, respectively, during a 6-month period, with sustained success. Statistical process control p-charts with standardized special-cause rules were used to determine performance over time.

Baseline ALD and CLD rates were 3% and 1%, respectively. During intervention 1, the ALD and CLD rates increased to 81% and 68%, respectively, with special-cause variation noted for both rates. During intervention 2, ALD increased to 90%, but CLD rates did not change significantly (66%). For intervention 2, the documentation of firearm/gun access (90%) was higher than documentation of access to sharps (68%) or medication (69%).

We achieved a significant increase in ALD and CLD for MH evaluations in our ED. Lessons learned may generalize to other ED settings.