Asking the Right Questions

Implementing behavioral health screening in a pediatric emergency department

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The Screening Protocol

Jessica Williams wants you to know that depressed kids don’t have a “look”. As the lead social worker in charge of the behavioral health screening protocol at Nemours/Alfred I duPont Hospital for Children, it’s her job to educate clinicians, staff, and families about the one thing they can do to identify kids in crisis: ask them the right questions. “Kids that appear to be depressed, whatever you think that might look like, they might not actually be depressed,” she explains. “And sometimes the kid with a suicide plan has tons of friends and makes straight A’s. We can’t make assumptions based on how a child appears.”

As “champion” of the screening protocol, Williams manages and evaluates the program, working concurrently with stakeholders at the Delaware Department of Services for Children, Youth, and Their Families. The protocol, which aims to screen all patients 12 years of age and older who are admitted to the emergency room, is first triggered when a nurse receives a best practice alert (BPA) through the hospital’s EHR system. The nurse then asks the patient to complete a behavioral health assessment on an iPad using a software program called BH-Works. This web-based survey asks patients questions about depression, trauma, substance use disorder, bullying, abuse, suicidal ideation, and gun access. Responses are automatically scored, summarized, and ready for review in the EHR, helping providers determine when a patient requires additional support. As a licensed clinical social worker, Williams also provides in-person clinical mental health assessments for patients who screen positive for risk.

Collaborative Implementation

Alfred I duPont Hospital for Children in Wilmington, Delaware

Introducing a new workflow in a busy care environment required strategic communication and implementation planning. When Williams joined the emergency department in early 2019, she was tasked with reaching out individually to each associate, confirming they knew about the protocol and understood their part in the process. This roster included over 150 nurses, social workers, attending physicians, fellows, residents, physician assistants, and nurse practitioners. She also educated ancillary staff about the screening process, including child life specialists, unit clerks, flow supervisors, and nursing leadership.

In addition to reaching out to individual staff members, Williams attended huddle meetings to answer questions, listen to feedback, and share case examples. One of the cases she talked about regularly involves a patient who was put into a fast track treatment process for a sports injury. When the teen was screened right before discharge, he disclosed that he was severely depressed, experiencing current suicidal ideation, and had made a suicide plan. These types of stories helped stress the importance of screening for behavioral health issues. “Initially, the nurses and providers were surprised by those patient stories,” Williams recalls. “Surprised at first that the protocol was working, and then surprised there were so many kids at risk.”

Williams wanted to help her associates through the inevitable growing pains of a new workflow, so she began troubleshooting issues with the help of an interdisciplinary team, working through a process she coined “collaborative implementation.” Her team actively involved providers and fellow associates as they worked to address kinks in the technology, workflows, and communication plan. “Sure, they know that they have to do this for their job,” she states. “But we’re asking them to do something that isn’t always the easiest or most comfortable thing, so it helps to bring them into the process.”

Configuring Workflows

Based on associate suggestions, Williams and her team created algorithms to guide nurses and providers through common scenarios, posting them in high-traffic areas. Williams is careful to point out that these algorithms are not hard and fast rules. She explains, “With behavioral health, we can’t always say, ‘Do a,b, and c’ every time a patient screens positive for severe depression. Sometimes that patient is on medication and working with a therapist, and the doctor doesn’t necessarily need to call down a social worker immediately.” 

Jessica Williams, LCSW (pictured left) explaining the BH-Works protocol to a nurse

Although the protocol aims to screen all eligible patients, many variables can stop or slow the process. To provide an appropriate course of action in all situations, the team worked with the hospital’s EHR analyst to add buttons to categorize specific responses to the best practice alert (BPA). “Acknowledge” is used to indicate that the screen was administered, and the BPA disappears after selecting that option. The “Clinically Not Appropriate” button is used when patients are admitted with conditions like traumas, severe migraine with aura, severe pain, or developmental delay. Selecting this option shuts the BPA off for the rest of the visit. A “Medical Delay” button addresses scenarios in which a patient may not be able to complete the screen when the BPA first comes through, but can do so after receiving minor treatment. This button is helpful when a nurse needs to administer anti-nausea medication or place an IV in the patient, “snoozing” the BPA for 25 minutes before it reappears on the screen. 

Once these buttons were activated, the hospital’s EHR analyst taught Williams how to track when an alert appeared in the system, what buttons were pressed, and by whom. Armed with this information, she was able to audit individual patient charts to understand issues on a case-by-case basis. “In the beginning, we were educating, educating, educating, but what we wanted to happen [screening all eligible patients] wasn’t happening,” Williams explains. “We had to figure out where things were breaking down.” Williams identified six common problems and worked with emergency department management to address them. For example, in order to remind providers to review the screening results, the team incorporated the provider BPA into the discharge process, a time that fit better into their workflows.

I can’t tell you how many times I’ve asked a kid why they hadn’t shared their feelings with someone before taking this screen, and they tell me it’s because no one had ever asked them.

Getting Results

These collaborative efforts quickly increased the number of patients screened in the emergency room. The month before the team started their collaborative implementation plan, only 20 patients had been screened through the protocol. After their first month of strategic efforts, that monthly screening number increased to 180. By the third month, the numbers jumped to 507. Currently, the team consistently screens between 32-49% of clinically appropriate cases monthly, an above average number compared to other hospitals with similar protocols. Williams and her team plan to improve the screening process through 2020, with a goal of screening 100% of clinically appropriate patients.

By the end of 2019, over 3,000 patients had been screened in the Nemours emergency department. Out of those patients, twenty-three percent (715 patients) reported symptoms of moderate to severe depression, twenty percent (609 patients) reported significant trauma, fifteen percent (479 patients) reported a history of suicide ideation, and 117 patients were actually contemplating suicide at the time of screening.

Williams is now educating other departments about the program, seeing potential for behavioral health screening throughout the Nemours health system. She urges providers across the country to consider implementing similar protocols. “Kids are literal beings,” she explains. “I can’t tell you how many times I’ve asked a kid why they hadn’t shared their feelings with someone before taking this screen, and they tell me it’s because no one had ever asked them. That’s why we have to do things like this. Because there’s no other way to know other than to ask.”