Development of Quality Measures for Pediatric Acute Agitation Management in the Emergency Department

Background: Mental health emergency department (ED) visits among children are increasing, with more visits involving acute agitation. Approximately 5-10% of children seen in the ED for a mental health condition require physical restraints, and pediatric ED visits with pharmacologic restraint use increased by 370% from 2009 to 2019. Quality measures are used to assess and improve healthcare quality, but there are no rigorously developed quality measures for pediatric agitation management in the ED. The objective of this study was to develop quality measures for pediatric agitation management in the ED informed by perspectives of multidisciplinary ED care team members and parents.

Methods: Through a modified Delphi process, a panel of multidisciplinary ED care team members and parents developed quality measures for pediatric agitation management in the ED. Initial measure drafting was informed by a literature review and website searches of professional societies and health care quality organizations. Panelists ranked measures in terms of importance and feasibility on a 9-point scale during two survey rounds, with a teleconference convened between surveys to discuss and modify measures. Consensus was defined by >75% of panelists ranking a quality measure highly in importance (score ≥7) and a median feasibility score ≥4. Each measure that achieved consensus was classified by the study team in terms of Donabedian classification and Institute of Medicine domain.

Results: Multidisciplinary panelists (n=36) included emergency medicine physicians, pediatricians, child/adolescent psychiatrists, nurses, social workers, security, child life specialists, hospital data analysts, and parents of children with psychiatric conditions. Panelists were 81% female, 69% non-Hispanic White, and 87% reported working at children’s hospitals. Survey completion was 100% (36/36) in both rounds, with 76% (26/36) teleconference participation. Figure 1 illustrates how measures were ranked and modified through the rounds of the modified Delphi process. The panel reached consensus on 20 quality measures for pediatric ED agitation management (Table 2). Measures with the highest percentage of scores in the high importance range (score ≥7) were related to medication adverse events, the number of patients restrained, staff/patient injuries, re-escalation plans, presence of a standardized care algorithm, formal staff training on de-escalation techniques, time to medication administration, and room safety. Thirteen measures (65%) were categorized as process measures, 5 (25%) as outcome measures, and 2 (10%) as structure measures. Seven (35%) measures addressed the Institute of Medicine domain of effectiveness, 7 (35%) safety, 6 (30%) timeliness, 5 (25%) patient-centeredness, and 4 (20%) efficiency.

Conclusion: Twenty quality measures for pediatric agitation management in the ED were developed through a consensus process that incorporated perspectives of multidisciplinary ED care team members and parents. Once operationalized and field-tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.