610 - Improving behavioral health care in a pediatric ED by implementing a standardized agitation score.

Publication Number: 1587.610

Niloufar Paydar-Darian, Boston Children's Hospital, Boston, MA, United States; Kathleen Kiley, Boston Children's Hospital, Boston, MA, United States; John J. Porter, Boston Children's Hospital, Boston, MA, United States; Caitlin Kent, Boston Children's Hospital, Norfolk, MA, United States; Megan Trexler, Boston Children's Hospital, Walpole, MA, United States; Jessica K. Creedon, Boston Children's Hospital, Dover, MA, United States; Joel H. Hudgins, Brown Emergency Medicine, Milton, MA, United States

Background: In recent years, there has been an increase in children and adolescents seeking care for behavioral health (BH) complaints in emergency departments (ED) across the United States. At our institution, the total hours of care devoted to BH patients tripled since the Covid-19 pandemic began, nearing 20,000 hours per month in 2022. This unprecedented surge strained ED resources, leading to increases in both ED internal events and restraint utilization.

Objective: We aimed to improve the safety and quality of care for BH patients by implementing a standardized agitation score as a signal for early intervention, with the goal of reducing restraint utilization in this patient population.

Design/Methods: We used the Model for Improvement to refine BH care at a quaternary care pediatric ED. Interventions included the introduction of the Modified Overt Aggression Scale (MOAS) to alert the team to increasing risk of agitation. A MOAS Huddle was required for scores ≥10. The huddle, between nurse and provider, focused on three action items (the "ABCs"): (A) the provider obtaining a patient-specific agitation plan from Psychiatry; (B) the nurse contacting the Behavioral Response Team; and (C) the team discussing coping and de-escalation strategies. We used statistical process control to evaluate performance. The electronic health record also transitioned during this period. Primary outcomes included the incidence of restraint utilization (pharmacologic or physical) and serious ED internal events. Process measures included the percentage of BH patients with an intake MOAS score (within 4 hours of arrival), any MOAS score during the encounter, and a documented MOAS Huddle. Our balancing measure was the percentage of BH 7-day return visits.

Results: Over the study period (Oct 2022-Sept 2025), there were 8,207 BH patients evaluated in the ED, totaling 283,562 hours of care. The percentage of BH patients with an intake MOAS score reached 70% (Figure 1), and those with any MOAS score rose to 78%. Of eligible patients, 57% had a MOAS Huddle documented. There was no change in overall restraint use (Figure 2). Pharmacologic and physical restraint rates also remained stable. Serious ED internal events decreased, with more than 3,379 BH encounters since the last event as of Oct 2025. There was no change in return visit rates.

Conclusion(s): Utilizing a standardized agitation score (MOAS) as an early signal for agitation risk, linked to a nurse and provider huddle triggering a cascade of action items, was associated with a reduction in serious ED internal events and consistent restraint utilization despite increasing BH volumes.

Figure 1
Percentage of behavioral health patients with an intake MOAS within 4 hours.

Figure 2
Percentage of behavioral health patients with any restraint.