Background: Currently, youth seeking emergent mental healthcare are often required to complete routine laboratory assessment, regardless of presentation, to ensure “medical clearance” prior to consideration of inpatient psychiatric care. These laboratory tests are often low yield and have the potential to cause significant trauma and avoidable restraint, particularly with youth. Furthermore, this introduces excess cost, spurious lab findings and delays in care for a system that is already constrained by long lengths of stay, inefficiencies, and excess cost. Several states have adopted evidence-based tools, or SMART clearance, and workflows to eliminate the use of routine laboratory findings for medical clearance and based this clearance on clinical presentation and judgment of medical and psychiatric staff.
Methods: We describe the project design and implementation of the MI-SMART tool (adapted from the Sierra Sacramento Valley Medical Society SMART project), via an initiative by the Michigan Department of Health and Human Services, at a large, academic, tertiary care children's hospital in the State of Michigan. This includes initial stakeholder development, including mental health professionals in consultation-liaison psychiatry, inpatient psychiatry and emergency psychiatry, pediatric hospitalists and intensivists, pediatric emergency department (ED) professionals, administrative and information technology staff, as well as partners at Community Mental Health and the Department of Health and Human Services. This stakeholder group met iteratively from January 2024-June 2024 to design workflows in the pediatric ED and psychiatric ED setting, as well as parallel workflows with the inpatient pediatric floors and pediatric critical care setting. The result was the piloting of a electronic medical record navigator with a standardized MI-SMART checklist and template for documentation, page alerts and best practice advisory alerts, workflows, tip sheets, and standardized education to operationalize the implementation of the MI-SMART resources. A data dashboard with key performance indicators was created to track process and outcome measures over time. The first three months of pilot data will also be presented as it relates to the relevant care of the pediatric population in the children's hospital.
Results: We will present stakeholder working group development, collaborative design of the MI-SMART resources, as well as pre-implementation data from the first three months of launching MI-SMART across the children's hospital. This will include review of process measures including number of MI-SMART forms utilized, acceptability of by providers and staff in the ED and hospital setting, number of youth successfully transferred to an inpatient psychiatric facility using the MI-SMART build and resources, time to triage in the ED to completion of the MI-SMART form, time to completion of the MI-SMART form and psychiatric consultation. Additional outcome measures that will be shared include routine labs and diagnostic studies gathered, cost, restraint use, as well as patient and family satisfaction.
Lessons Learned: Use of an evidence-based set of resources to mitigate the use of potentially unnecessary and traumatizing routine labs for medical clearance of youth requiring psychiatric admission may be a feasible, acceptable, and cost-efficient alternative to current medical clearance practice, while improving safety practices and patient, family and staff experience.
Learning Objectives:
Understand current evidence related to best practice for medical clearance of individuals, particularly youth, who require psychiatric admission from emergency settings.
Describe the process of designing an evidence-based tool to employ clinical judgment and best practice in supporting medical clearance of youth in the ED setting, rather than routine labs.
Review process measures and clinical outcomes resulting from initial data gathering on the implementation of the MI-SMART form and resources at a single, academic children's hospital.
Speakers KK
Medical Director, Nyman Inpatient Family Unit, C.S. Mott Children's Hospital, University of Michigan-Ann Arbor
Dr. Kruse is board certified as a Forensic Psychiatrist and Child and Adolescent Psychiatrist. She serves as faculty at the University of Michigan and is Medical Director of Child Inpatient Psychiatry. She is active in clinical activity, teaching and quality improvement in emergency...
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Division Director, Service Chief, Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan- Ann Arbor
Dr. Malas holds dual appointment in the Department of Psychiatry and the Department of Pediatrics at the University of Michigan. He previously served as Director of Pediatric Consultation-Liaison Psychiatry at C.S. Mott Children's Hospital for nine years, prior to becoming the Division...
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