Comprehensive Care Bundle

Resource leader: Joyce Li MD MPH

Team members: Ashley Foster MD, Kathleen Kiley, Nicole O'Callahan, Melissa Sundberg MD

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This packet contains a comprehensive care plan for pediatric patients with behavioral health symptoms that are boarding in your emergency department.

The goal of this resource packet is to give you tools that will enhance the care of children with behavioral health symptoms that are boarding in your emergency department awaiting psychiatric care/disposition. The resources included in this packet are à la carte- take what is most helpful to your ED. There are many different forms and tools in this packet and we do not expect or recommend for you to adopt all of them at once. We would recommend reviewing all the tools and then choosing one tool at a time for your ED depending on what your ED needs most.

Many of these forms can be edited to individualize to your needs as we understand that every ED is unique and has different resources and ED staff available (ex: access to a shower). You can also use these tools as suggestions on how to improve existing resources/tools that you may have in your ED. These tools were crafted so any ED can use them, including those with limited pediatric resources, behavioral health support, or ED staffing. These tools were not designed to be a part of an ED’s electronic medical record- their primary purpose is to both facilitate communication between ED staff, patients, families and individualize the care for children who are experiencing ED boarding.

In this packet, you will find several resources:

Safety

  1. ED Behavioral Health Intake Form
  • This is a communication tool to ensure that all necessary safety precautions and screening has occurred.

2. Daily Behavioral Health Tracking

  • This tool is a grid that includes daily activities of living and other safety items that are important to monitor while a pediatric patient is boarding in the ED. The goal of this tool is to serve as a communication tool between shifts for all staff including sitters/observers to both track what has been done and also as a reminder of what should happen every day (e.g. meals).

3. ED Behavioral Safety Rounds

  • This tool is a suggested guide to guide patient rounds for boarding patients to ensure patient safety.

4. Core Principles of Behavioral Healthcare Information Sheet

  • This tool is an informational sheet that reviews general guiding principles in caring and approaching patients who are in a behavioral health crisis that can be used for onboarding and reminder to staff.

5. Behavioral Health Handoff

  • The goal of this tool is to help ensure that all necessary information is passed off and reviewed during patient signout/handoffs.

6. ED Safety Room Checklist

  • This form is a checklist to ensure that all ED rooms are safe and secure for a patient with a behavioral health condition.

Patient-Centered Care

  1. Coping tool
  • The aim of this tool is to provide safe and patient-centered care to children in the ED experiencing boarding with behavioral health conditions by identifying specific triggers and coping mechanisms for the patient.

2. Daily Schedule

  • The goal of this tool is to help provide structure to the day for pediatric patients while they are experiencing ED boarding for behavioral conditions.

3. What to Expect in the ED

  • The “What to expect” tool contains a patient handout and script/talking point guides for common topics that come up during a patient’s ED stay for a behavioral health condition.

Introductory Video

Please watch the video for an introduction to items in this packet.

This is a communication tool to ensure that all necessary safety precautions and screening has occurred upon initial patient intake.


This form is a communication tool to ensure that all necessary safety precautions and screening has occurred. This checklist should begin to be filled out by the ED staff member who is initially placing the patient into an ED room and should be updated by any ED staff who participates in the items below after mental health evaluation and as needed during their stay. It should be kept with the patient so that ED staff can use it as a reference tool for that patient. Check marks should be placed next to items as they are completed and complete portions of form as instructed.

This form serves 2 purposes: 1) to ensure necessary safety precautions and screening are completed upon patient first arrival and during their initial assessment, 2) to be a communication tool that allows all those who are caring for the patient while they are boarding to see what has already been completed

We recognize that all EDs are very different with different needs and resources. The form is customizable for what you may already have in your EDs and to adjust for your own EDs policies and procedures.

We recognize that some of the checklist items below you may already have. For some specific items, we have provided additional tools within the New England Behavioral Health Regional Toolkit. Items below with an * are available in the New England Behavioral Health Regional Toolkit.

Behavioral health intake

This tool is a grid that includes daily activities of living and other safety items that are important to monitor while a pediatric patient is boarding in the ED.  The goal of this tool is to serve as a communication tool between shifts for all staff including sitters/observers to both track what has been done and also as a reminder of what should happen every day (e.g. meals).


This tool is a grid that includes daily activities of living and other safety items that are important to monitor while a pediatric patient is boarding in the ED. The goal of this tool is to serve as a communication tool between shifts for all staff including sitters/observers to both track what has been done and also as a reminder of what should happen every day (e.g. meals).

  • For any shift, ED staff should check this sheet at the beginning of their shift to see what has and hasn’t already done that day and refer to what remaining needs to be completed. After the sheet has been reviewed, the ED staff member should fill in the shift date time at the top if it hasn’t been completed already by another staff member. The whole ED team should then fill out items below as they happen during that shift.
  • For each category, circle what the plan is: Example for constant observe: care companion vs security for observer.
  • We recognize that all EDs are unique and have different resources and support available. Additionally, you may also be tracking many of these items already via other sources including your EMR. We highly encourage you to edit the items below for what best serves your ED which could include removing items that are already being tracked via another route or are unavailable in your institutions (e.g. showers).

Daily Behavioral Health Tracking

This tool is a suggested guide to guide patient rounds for boarding patients to ensure patient safety.


Introduction to Daily Behavioral Safety Rounds Guide

This tool is a suggested guide for daily safety reviews for pediatric patients who are boarding in the ED with a behavioral health condition. We would suggest that safety reviews happen twice a day but this can be adjusted as needed for your ED. The tool has various sections to allow for customization for your EDs needs, staffing and workflow.

We would suggest the following to best use this tool

  1. Decide how this review sheet can best be incorporated into the workflow for your ED. For example, is there a specific time of day that you already review or round on patients in the ED or when your mental health providers review the patients in your ED? ED individual staff sign-out would also be a good time to consider to do these reviews. You can either have pre-assigned times which can be filled out in the additional notes section or you can use the time of review section to track the completion of the daily reviews. You can add on additional tracking to the back of the sheet.
  2. Decide what ED team members in your ED should participate in the safety review. This should include the bedside ED nurse but can also include the charge nurse, behavioral health team members, ED physician, or any other relevant personnel for your ED.
  3. Please use the “Who participates” pink box on the left to fill out what ideal team members should participate in the daily safety review.
  4. An additional notes section has been provided to allow for any additional items that should be reviewed for your ED or other customizations to help facilitate utilization of this tool.

Behavioral Safety Rounds

This tool is an informational sheet that reviews general guiding principles in caring and approaching patients who are in a behavioral health crisis that can be used for onboarding and reminder to staff.


This tool is an informational sheet that reviews general guiding principles in caring and approaching patients who are in a behavioral health crisis. This sheet can be used to help with the onboarding process of any new ED staff including observers. It can also be posted in the ED, for example in charting areas or staff workrooms, as a reminder to staff caring for these patients.

Core Principles

The goal of this tool is to help ensure that all necessary information is passed off and reviewed during patient signout/handoffs.


The goal of this tool is to help ensure that all necessary information is passed off and reviewed during patient signout/handoffs. Structured handoffs have been shown to improve patient care and safety by ensuring consistent, reliable information during transitions of care. The tool below is a structured handoff tool to help guide handoffs specifically for patients boarding in the ED for behavioral health conditions. We recognize that all EDs are different and so we have provided a version that you can edit to fit the needs of your ED. It is important to help orient your staff on how to use this tool which is to make sure that each section should be reviewed and to use this tool as a guide. Staff can fill out the information if it will help ensure all necessary information is passed off during transitions of care.

Behavioral Health Handoff Tool

This form is a checklist to ensure that all ED rooms are safe and secure for a patient with a behavioral health condition.


This form is a checklist to ensure that all ED rooms are safe and secure for a patient with a behavioral health condition. This checklist should be used primarily for ED rooms not specifically designed for patients with a behavioral health condition (e.g. safe rooms).

This should be filled out prior to the patient entering an ED room by the ED staff member assisting with placing the patient into an ED room when the patient first arrives. It should be kept with the room that the patient was placed in so that ED staff can use it as a reference tool for that patient. Check marks should be placed next to items as they are completed.

We recognize that all EDs are very different with different needs and resources. The form is customizable for your ED rooms and to allow you to adjust for your own EDs policies and procedures.

This tool can be used in conjunction with Behavioral Health Intake Form (see first tool of packet) or on its own.

Room Safety Checklist

The aim of this tool is to provide safe and patient-centered care to children in the ED experiencing boarding with behavioral health conditions by identifying specific triggers and coping mechanisms for the patient.


The aim of this tool is to provide safe and patient-centered care to children in the ED experiencing boarding with behavioral health conditions. Identifying triggers to agitation and coping mechanisms that work well for the individual child may help to reduce behavioral dysregulation and/or agitation episodes while in the ED. We recommend offering this tool to patients and their caregivers early on during the patient’s ED stay to complete. Answers provided by the patient/family will help to better understand possible triggers for the patient and what activities or items best help the patient cope when they are upset.

This tool can be printed and offered to patients and/or their caregivers. For patients and/or caregivers who are unable to read or do not understand English, the tool can be verbally reviewed. Ideally, the completed tool can be kept with the patient’s information/chart for reference for other ED staff during their stay.

You can use the script below when offering the coping tool to caregivers and/or patients.

This is the coping tool to help us better understand how best to care for you/your child while you/they are in the ED. Please complete the questions to the best of your ability to help us better understand what can cause you/they to become upset and how we can best make you/them feel better.

coping tool

The goal of this tool is to help provide structure to the day for pediatric patients while they are experiencing ED boarding for behavioral conditions.


The goal of this tool is to help provide structure for pediatric patients while they are experiencing ED boarding for behavioral conditions. Lack of structure can be difficult for children while they are boarding in the ED for hours to days. Providing structure can help children know what to expect throughout the day and help to ensure that children have activities of daily living and enrichment activities during each day of ED boarding. In the tool attached, the first page is an information handout from the Emergency Nurses Association about how to provide structure for these patients. The second page is a template schedule for you to use. We recognize that all EDs have different resources and staffing so this schedule is provided in a format that you can edit to your ED’s needs.  

A daily schedule can enhance patient safety and patient-centered care. We recommend a daily schedule to be completed by ED staff with patient and/or caregivers(s) each day while boarding in the ED. This can be either completed in the morning or in the evening to plan for the next day. You can modify the schedule to ensure it is specific to the resources of your ED.

This tool can be paired with the Activity Resource also contained in the New England Behavioral Health Toolkit Activity Resource Packet. For the “movement/exercise activities'' and general “activities” listed in the daily schedule marked with an *, you can consider offering the self-care activity packet for the patient and/or caregivers. If funds are available, your ED can purchase items from the activities purchasing guide to offer to patients and/or caregivers as activities while boarding in the ED.

*The Self Care Activity Binder within the New England Toolkit Site has a list of activities to choose from

Modified daily schedule

The “What to expect” tool contains a patient handout and script/talking point guides for common topics that come up during a patient’s ED stay for a behavioral health condition.


The “What to expect” tool contains a patient handout and script/talking point guides for common topics that come up during a patient’s ED stay for a behavioral health condition. This tool is meant to help assist in informing parents and caregivers on a variety of common topics that come up during the ED stay. This has been reviewed by parents of pediatric patients with behavioral health conditions.

In this tool, you will find the following:

Item 1: What to expect during your Emergency Department (ED) stay for a Behavioral Health condition

  • This is a patient handout that you can give to caregivers of pediatric patients who are coming in for a behavioral health evaluation. This can be given to patients after they have been triaged. The goal of this handout is to explain how the ED visit works for behavioral health evaluations and next steps. This handout is in word format so you can add/edit additional information that is specific to your ED.
  • Please be aware that not all caregivers and patients may be able to read or understand English. For these patients, consider reading this sheet and/or using a translator service as a script to these patients and caregivers

Item 2: Difficult conversation talking points guide

  • This is meant to be used by ED staff ONLY. This guide contains talking points to help guide discussions on different topics that often come up during a pediatric patient’s stay for a behavioral health condition. These should usually be discussed after the mental health evaluation but can be used prior if the caregivers ask questions about these topics.
  • DO NOT GIVE the guide as a handout to patients/families to read on their own. The contained topics can be difficult conversations for caregivers and patients, especially if they have not encountered the information below before. Caregivers and patients new to this process will likely have other questions and may have confusion or anger in response to these topics and, therefore, these topics should be introduced as a conversation from the ED staff.
  • Included topics: Different levels of psychiatric care, Involuntary holds, Long boarding times in the ED

Another helpful resource that can be shared with parents is the primer about going to the emergency department below from the Child Mind Institute.

https://childmind.org/article/taking-a-child-to-the-emergency-room/

What to expect in the ED

We hope that you will find this resource helpful!

Please contact the resource leader, Joyce Li, with any questions!