If you think about the emergency department, it’s often the front door to your hospital. You can’t close that front door—it’s always open.

Yet in terms of staffing shortages and a lack of inpatient beds, the emergency department is where the pressure builds up, explains Shelby Chapman, Director of Patient-Family Experience at Children’s Hospital Colorado.

Chapman analyzed a quadrafecta of issues affecting patient-experience scores: the early respiratory season and COVID-19, the pediatric behavioral-health crisis, resiliency burnout, and staffing shortages. These challenges, shared during the NRC Health 2022 Pediatric Collaborative at Children’s Hospital of Alabama, caused Chapman to deep-dive into their patient comments to find out how to best support their ED team.

Chapman’s analysis indicated that their typical response would not work; they needed a new plan. Specifically, Chapman inquired about the modifiable factors they might be able to influence, knowing that ED staff couldn’t add anything more to their responsibilities.

“What we were looking for was, when patients gave us their highest rating, what were they saying that was specific about that experience?” Chapman says. “With our families, we could see comments [to the effect] that if they felt that the space was clean and felt safe, they trusted us with their care differently.”

Chapman found that clean and safe, child-friendly environments incorporating clear communication, compassion, and efforts to ease worries made patient/family experiences great. So the organization went to work putting together a plan around education/information, wait-time updates, people resources, and support for the psychiatric ED.

“Everywhere else you go in your life, it’s first come, first served,” Chapman says. “The emergency department and urgent-care system don’t work that way. Our families didn’t necessarily understand the concept of triage. So we created a simple tool to explain the process and give them a baseline for understanding how it works in the ED. They were printed on pull-up banners in English and Spanish and used in the waiting room of every one of our ED urgent cares.”

Chapman said they’d gotten some feedback that a family of color had waited, but saw other people who looked healthy going in before they did. It was a serious issue, and Children’s Hospital Colorado wanted to make sure there wasn’t any bias in the system. Looking into the issue, Chapman found out that the group who had gone back first was there for a mental-health crisis.

“They don’t have a fever, aren’t throwing up, and don’t have a broken bone,” Chapman says. “You can’t necessarily look at a patient and know why they’re there. But we have a psychiatric ED and a medical ED. Psychiatric patients get roomed faster, because we want to keep them safe and offer support to get them back quickly.”

To address this, the organization added information to a brochure explaining that patients with a mental-health crisis were seen in their psychiatric emergency department. They explained that mental-health patients were moved to a room as quickly as possible, which addressed why some might get roomed faster while keeping HIPAA information private. They also added that some patients were “coming by ambulance and helicopter that you don’t see,” for context.

As for wait times, they created a process to have a charge nurse with one of the physicians come out to share the script, which didn’t give a wait time but explained, “We know the wait is longer than normal. We see you, and we know this is hard. If something has changed with your child, please let us know.” While this was positively received, it was hard to do consistently.

So they moved on to people resources, thinking about whom their system could bring in to support the ED. Fortunately, volunteers were able to come back onsite after the initial part of the pandemic, and they came up with activity bags for kids or offered comfort items like donated fleece blankets.

The organization also brought child-life assistants into all ED waiting rooms to support patients and families. For example, if a child-life assistant noticed that a mother was stressed, she might get out a board game and play with the kids for 10 or 15 minutes so that the mother could take a phone call, making a difference for that mom at that moment. Over time, the organization got a permanent full-time resource to support this effort.

They then partnered with their environmental-services teams to help with overflowing waiting rooms, and used leader rounding more regularly in waiting rooms. They also added a new role to welcome, badge, and screen for families, while offering empathy, information, and light cleaning.

Children’s Hospital Colorado’s CEO declared a state of emergency for pediatric mental health in Colorado, so to support the psychiatric ED, Chapman explains, they trained and used patient advocates or patient-family experience teams to help answer basic questions and support families while they waited for an inpatient bed.

“The biggest thing they could do was just offer to listen,” Chapman says. “We gave families some permission to take care of themselves while they were worrying about their child who was having a mental-health crisis, and then offered them those basic comfort items.”