Autism Spectrum Disorder and the Emergency Department: A Quality Improvement Project

Background:

Autism Spectrum Disorder (ASD) includes classical Autism, Asperger’s, and Pervasive Developmental Disorder.  ASD is a life-long neurodevelopmental and neurobehavioral disorder afflicting one out of every 68 eight- year-old children in the U.S.  The CDC reported that of these 1-68 children, 1-42 are boys and 1-189 are girls.  The CDC surveillance summary found that 31% of these children had IQ scores in the disabled range (<70), 23% were in the borderline range of 71-85, and 46% were of average or above average.  Autism Spectrum Disorder occurs in all races, ethnic and socioeconomic groups.  This is a patient population that will be permanently present in our practices.  This increase in patients with Autism Spectrum Disorder (ASD) will require an improvement in the understanding of the disorder and methods for providing care to these patients. An increased prevalence in the last six years highlights the importance of ED staff awareness to effectively identify the disorder and associated behaviors when assessing and treating these patients.  Several common psychological and medical comorbidities to ASD impact patient care in the emergency department.  Comorbidities include Attention Deficit Hyperactivity Disorder, anxiety, depression, obsessive-compulsive disorder, learning disabilities, seizures and epilepsy, sleep disorders, gastrointestinal disorders, and catatonia.

 Purpose:

Understanding the underlying disorder and comorbidities would facilitate timely implementation of effective nursing interventions that decrease stimuli, provide comfort, and enhance communication with the patients.  Therefore, increasing professional nurse awareness of Autism Spectrum Disorder in the Emergency Department (ED) was essential to achieve quality patient outcomes. 

 EBP Project:

To enhance ED nursing staff awareness, an evidence-based quality improvement project was developed and implemented. There are two main domains concerning diagnosis criteria of Autism Spectrum Disorder which are; deficits in social communication and social interaction and restricted or repetitive behaviors or interests. The deficits in social communication and social interaction are significant and impact daily life. Frequently seen symptoms with this diagnosis are the following: impairments in social interaction, fixation on objects, pronoun reversal, hyperactivity, low frustration tolerance, concrete thinking, repetitive actions and/or words, over-stimulation, hypersensitivity and hyposensitivity.  The hypersensitivity and hyposensitivity symptoms of this disorder are significant challenges for these individuals.  Their responses to stimuli are jumbled.  They may be significantly oversensitive to sound, touch, sight, smells and taste.  They may not recognize a typically painful injury.  There has been some research that suggests those with ASD and ADD/ADHD have higher rates of injuries requiring medical attention.  Another study found that patients with ASD had a significant increase in requiring an emergency department visit due to a psychiatric reason versus a non ASD pediatric patient.  The difficulties that individuals with Autism Spectrum Disorder face are staggering.  These difficulties are increased an emergency department.  Emergency departments are loud, chaotic, hurried and bright environments.  The individual with ASD presenting to the emergency department is injured or ill.  This special patient population may have significant issues with communicating with the healthcare providers in the emergency department. Currently there is limited training or awareness concerning this patient population.  In addition, there is a limit to strong evidence concerning the best practices for providing patient care to individuals with ASD in the emergency department or concerning educational programs on best practices for ASD patients in the emergency department.  It is critical to begin educating emergency department staff concerning Autism Disorder Spectrum and that further research will continue concerning best practice for patient care for individuals with ASD.  The research for the educational presentation was obtained from various professional journals. I utilized research concerning visual cue cards, desensitizing techniques and transition planning from pediatric nursing, behavioral pediatrics, and medical journals. Successful implementation of the quality improvement project required the engagement of key stakeholders.  Key stakeholders included resource staff at the South Carolina Autism Society, the ED nurse manager, the ED nurse educator and the ED nurses.  Stakeholders aided in the development and implementation of an education presentation to enhance staff awareness of ASD.  This presentation included visual cue cards, appropriate computer applications, and tools for communication and sensory overload.

 Methods:

The educational presentation was presented to staff members of the emergency department during mandatory staff meetings to ensure maximum exposure.  The program content included definition of the disorder, incidence statistics, signs and symptoms of the disorder, and evidence based practices for the care of diagnosed patients.  The presentation included pictures of staff members and their children with ASD to increase the impact of the presentation.  Staff members requested to have pictures of their children and families included in the presentation. 

 The educational presentation included innovative learning strategies such as power point presentations, discussions, and follow up feedback. These strategies were utilized to ensure maximum effectiveness by addressing the various learning styles and the needs of the adult learner.  These learning strategies addressed the visual, auditory and kinetic learner in a concise format.  ED nursing staff was instructed on the importance of querying patients and family members concerning Autism Spectrum Disorder during the triage and assessment phases of the ED visit. This ensured that appropriate nursing interventions could be implemented for this specific patient population.

 Outcome:

Based on subjective post-implementation  follow up resulted in a change in practice due to an increase awareness of Autism Spectrum Disorder in emergency department patients.  The emergency department nurses state improved awareness of the disorder and techniques for providing patient care.  The program outcome, to implement evidence-based quality improvement practices and improve efficacy of assessment and treatment of patients diagnosed with Autism Spectrum Disorder was achieved. The statistics and the personal impact of staff members with ASD children assist in long term sustainability of the quality improvement project.  The quality improvement project is nearly budget neutral.  The education presentation is delivered during mandatory staff meetings, which are budgeted.  Maintaining a concise, informative presentation will minimize the disruption in the agenda for staff meetings and preserve the time constraint.  The educational presentations will be presented by volunteers.