O1027: Improving Lethal Means Safety Counseling Documentation Rates for Adolescents with Mental Health Concerns in a Pediatric Emergency Department

Purpose/Objectives: Lethal means safety counseling (LMSC) is recommended for children presenting to the emergency department (ED) for a mental health evaluation (MHE). No current gold-standard guidelines exist for MHE ED documentation of LMSC, and our ED had anecdotally rarely documented LMSC.

Design/Methods: At our tertiary children's hospital ED, we included patients ≥12 to 18 years old who presented with a MH concern, all of whom got a request for a MHE by our licensed clinical social workers (LCSW). We excluded external transfers, admitted patients, and left without being seen. A random sample of 20 electronic health record (EHR) charts were retrospectively reviewed manually each month. Baseline data from 4/2023 to 7/2023 were analyzed for any LMSC documentation (ALD) for "firearms/guns," "sharps," and "medications" access, and complete LMSC documentation (CLD) if all three types were documented. The quality improvement team began on 8/2023 with the first Plan-Do-Study-Act (PDSA1) by adding open-ended screening questions of all 3 types of access to the MH LCSW note template (Fig1a). The quality improvement team met with the LCSW and co-designed an EHR powerform (Fig2b) for easier LMSC documentation implemented in 8/2024 (PDSA2). We aimed to increase ALD and CLD to >75% and >50%, respectively, over a 6-month period with sustained success. We used statistical process control p charts with standardized special cause rules to determine significance; a p value less than 0.05 was considered significant to compare proportions between PDSA periods.

Results: The baseline ALD and CLD rates were 3% and 1%, respectively (Fig 2a, 2b). During PDSA1 period, ALD and CLD rates significantly increased to 81% (p < 0.001) and 68% (p < 0.001), respectively, with special cause variation noted for both rates. During the PDSA2 period, ALD increased to 90% (p=0.024) but CLD rates did not significantly change (68%, p=0.99). During PDSA2, LMSC documentation of gun/firearm access (89%; Fig 2c) was significantly higher than knife access (69%; p< 0.001; Fig 2d) or medication access (71%; p< 0.001; Fig 2e).

Conclusion/Discussion: We met our aims to significantly increase any and complete LMSC documentation for MH evaluations in our ED. Future PDSA cycles will aim to address suboptimal powerform utilization and other barriers. Lessons learned may generalize to other ED settings.