Implementation of the Agitated Behavior Scale in the Electronic Health Record

Abstract

Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide and can result in various consequences including behavioral disturbances such as agitation. The occurrence of agitation during the recovery of brain injury can interfere with the achievement of rehabilitation goals. It is thus important to identify agitation early with a valid assessment tool and provide timely interventions to reduce it. Purpose: The purpose of this study was to implement an Agitated Behavior Scale (ABS) through an electronic health record and to evaluate the usability of the ABS in a traumatic brain injury unit at a rehabilitation hospital in the Mid-Atlantic region of the United States. Methods: A quality improvement project was conducted in the brain injury rehabilitation unit in three phases that included an in-service education, implementation of the ABS in electronic health record and administration of survey questionnaire. It consisted of 755 electronic ABS chart reviews and a sample of 23 registered nurses of the brain injury unit. Results: Results showed that there was good compliance in the use of the ABS in the electronic health record and in the implementation of interventions for agitation among the TBI patients. The survey questionnaire findings confirmed that the electronic ABS was found to be utilizable and practical. Conclusion: Utilization of the ABS through the electronic health record on a daily basis will allow for an early identification of agitation in TBI inpatients in the hospital and enable prompt interventions to manage agitation thus promoting positive outcomes for the patient.