Implementation of the Agitated Behavior Scale for Hospitalized Children With Acquired Brain Injuries: A Quality Improvement Initiative

INTRODUCTION: Agitation occurs in up to 71% of hospitalized patients with acquired brain injuries (ABIs). Despite its prevalence, agitation in pediatric ABI is often assessed subjectively, and standardized assessment tools are inconsistently used in pediatric settings. This quality improvement initiative was designed to address this gap by implementing a standardized agitation assessment and evaluating its feasibility and impact on documentation and nursing knowledge. OBJECTIVE: Use a standardized assessment tool with formal education to improve agitation documentation, nursing knowledge, and nursing confidence of pediatric, brain-injury related agitation. DESIGN: Quality improvement initiative using a before-after design. SETTING: Academic, tertiary pediatric hospital. PARTICIPANTS/PATIENTS: Children aged 5-18 years hospitalized with ABI and agitation who had an Agitated Behavior Scale (ABS) ordered; Nurses of these patients. INTERVENTIONS: The quality improvement team developed nurse-focused education on pediatric ABI-related agitation and the ABS, administered pre- and post-tests assessing knowledge and confidence, and implemented an electronic medical record (EMR) order and flowsheet for ABS documentation. Nurses charted the ABS at least once per 12-hour shift for patients with an ABS ordered. MAIN OUTCOME MEASURES: Adherence to documenting the ABS once per shift, nursing knowledge of agitation and the ABS, and nursing confidence with agitation and the ABS. RESULTS: ABS documentation adherence improved from 0% to 97% (205/211 shifts) over 9 months after implementation. For 8 nurses who completed pre- and post-tests, knowledge scores and confidence with ABS improved after education (P = 0.008; P = 0.016). Confidence with agitation did not improve (P = 0.063). CONCLUSIONS: Implementation of targeted nursing education combined with an electronic ABS order and flowsheet was associated with substantial improvements in adherence to objective documentation of agitation in hospitalized children with ABI. Standardized assessment of agitation in pediatric ABI may support more consistent clinical care and provides a foundation for future, multisite research.