146 - Improving Care for Autistic and Neurodivergent Patients in the Pediatric Emergency Department

Publication Number: 3140.146

Dilruba Khanam, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States; Patricia Brill, Stony Brook Medicine, East Setauket, NY, United States; Laura A. Pantusco, Stony Brook Children's Hospital, Port Jefferson, NY, United States; Lee Popick, Stony Brook Children's Hospital, Saint James, NY, United States; Carl Kaplan, Renaissance School of Medicine at Stony Brook University, Old Bethpage, NY, United States

Background: The sensory-rich environment and frequent interactions with unfamiliar healthcare providers in the emergency department (ED) can be overwhelming for children and youth with Autism Spectrum Disorder (ASD) and other neurodivergent conditions, increasing the risk of behavioral escalation and safety challenges. Standardized guidelines, sensory-friendly strategies, and family engagement have been shown to mitigate risks as well as improve patient safety and experience. However, the effectiveness of a de-escalation care pathway on the delivery of efficient emergency care to this population remains unclear.

Objective: The objective of this quality improvement (QI) project was to evaluate the impact of a patient-centered de-escalation care pathway on the pediatric ED (PED) length of stay (LOS) for our target patient population.

Design/Methods: In March 2024, we convened as a multidisciplinary QI collaborative to adopt a standardized, multimodal de-escalation approach for managing agitation and/or anxiety in autistic and neurodivergent patients seeking medical and/or psychiatric care in our PED. Our care pathway integrated the Emergency Medical Services for Children (EMSC) Pediatric Education & Advocacy Kit agitation guideline, a sensory toolkit, environmental redesigns, and a clinical decision tool, with the goal of 20% improvement across all metrics. Monthly retrospective chart reviews were conducted to assess the effects of several PDSA cycles on measures including multiple medication dosing for behavioral control, time elapsed from ED arrival to lab acquisition, completion rate for full set of vital signs, and mean PED LOS for discharged patients, comparing pre- and post-intervention data. Patients were identified using ICD-10 diagnostic codes for neurodevelopmental conditions.

Results: A total of 2104 eligible patients were included: 1540 in the pre-intervention phase (January 2022-June 2024) and 564 in the post-intervention phase (July 2024-September 2025). There was a reduction in the percent of patients requiring greater than two medication doses (pre 14.7% versus post 2.2%), meeting our goal. The completion rate for full set of vital signs increased (pre 63% versus post 73.6%), and the time to lab acquisition decreased (pre 114 minutes versus post 96 minutes). Although the mean PED LOS for discharged patients decreased by only 3%, no increase was observed.

Conclusion(s): The implementation of a care pathway tailored to our target population optimized clinical assessments, task completion, and judicious medication administration. These improvements contributed to a favorable impact on the mean PED LOS.

Patients with Autism/Neurodevelopmental Diagnosis Requiring More Than Two Doses of Medication
There was a decrease in the percent of patients with autism and/or neurodevelopmental diagnosis requiring more than 2 doses of medications for behavioral control from baseline mean of 14.7% to 2.2% (85% reduction).

Average Time Elapsed from PED Arrival to Labs Drawn
There was a reduction in the time elapsed from PED arrival to lab acquisition from the baseline mean of 114 minutes to 96 minutes (16% reduction). There was also a decrease in variability.

PED LOS for Discharged Patients with Autism/Neurodevelopmental Diagnosis
There was a slight decrease in the mean PED LOS from 228.6 minutes to 220.9 minutes for discharged patients with autism and/or neurodevelopmental diagnosis (3.4% reduction).