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

Abstract

Objective: Pediatric mental health emergency department (ED) visits that involve restraints for agitation are increasing. Quality measures are used to assess and improve healthcare quality. Our objective was to develop quality measures for pediatric ED agitation management informed by multidisciplinary perspectives.

Methods: A multidisciplinary panel developed quality measures for pediatric ED agitation management through the modified Delphi method. Panelists ranked measures in importance and feasibility on a 9-point scale during 2 survey rounds, with a teleconference discussion between surveys. Consensus was defined by >75% of panelists ranking a quality measure highly (≥7) in importance and a median feasibility score of ≥4.

Results: Panelists included 36 physicians, nurses, social workers, security, child life specialists, hospital data analysts, and parents. The panel reached consensus on 20 quality measures. Measures with the highest percentage of scores with importance ≥7 were related to adverse medication events, patients restrained, staff/patient injuries, reescalation plans, presence of an algorithm to standardize care, formal staff training on deescalation techniques, time to medication administration, and room safety.

Conclusions: Twenty quality measures that incorporate multidisciplinary perspectives were developed for pediatric ED agitation management. Once operationalized and field tested, these measures may be used to assess and improve healthcare quality for pediatric agitation.

Figure 1.. Sample Score Card for Delphi Round Two

Delphi panelists were provided scorecards with information from the first survey and teleconference to re-rank controversial quality measures. Score cards consisted of a de-identified summary of representative comments submitted by other panelists, histograms displaying the score distribution for each measure from the first round, the median score for each measure, and an indication of the panelist’s score for each measure in the first round. ED: emergency department; RN: registered nurse.

Figure 2.. Modified Delphi Process to Develop Quality Measures for Pediatric Agitation Management

The modified Delphi process for the development of quality measures consisted of a literature review to inform an initial set of quality measures, panelist ranking of quality measures on their importance and feasibility, a teleconference to allow panelists to discuss controversial quality measures and propose additional measures, and a second round in which panelists re-ranked controversial measures and ranked newly proposed measures. The process resulted in 20 quality measures that reached consensus.

Figure 3.. Heat Maps of Importance and Feasibility Rankings for Quality Measures by Panelist Type

Quality measures are displayed in order of the percentage of panelists who ranked the measure as high in importance and are grouped by whether or not the quality measure achieved the study definition of consensus among panelists. Median importance, median feasibility, the percentage of panelists who ranked the measure as high in importance, and the percentage of panelists who ranked the measure as high in feasibility are displayed by panelist type and shaded with the lowest rankings in orange, middle rankings in yellow, and highest rankings in green. The full measure text corresponding to each brief measure description can be found in Table 1 and Supplemental Table 2.