A Front-end Redesign With Implementation of a Novel "Intake" System to Improve Patient Flow in a Pediatric Emergency Department

Rapid cycle QI methods ensure prompt paediatric emergency care during 2022 respiratory surge

OBJECTIVES

In fall 2022, paediatric EDs (PEDs) and urgent cares (PUCs) cared for an unprecedented number of children, leading to long waits and boarding patients. This surge mimicked the adult ED/UC COVID-19 pandemic experience. Learning from published data and surge response plans, we adapted our response using rapid cycle quality improvement methodology.

METHODS

A multidisciplinary PUC/PED team met to determine the current state and create interventions. After the standard seasonal surge response did not have a significant impact, we further expanded inpatient capacity, created new physical PUC space, started provider intake and transitioned PED beds to inpatient.

RESULTS

Statistical control charts were used to monitor metrics from 4 weeks prior to the surge to when volumes returned to baseline, but improvement was seen prior to this. Our primary outcome measure, left without being seen (LWBS) rates, decreased from a peak of 40% to <5% and PUC door-to-provider time (process measure) decreased from 158 min to 106 min before the surge was over. These metrics also dropped below the prior baseline after volumes returned to normal. PED door-to-provider time (process measure) and PUC lengths of stay (LOS) (balancing measure) were maintained throughout.

CONCLUSIONS

Using rapid cycle methodology, we responded quickly to an unprecedented patient volume by innovatively increasing staffing and space. We improved LWBS rates and PUC door-to-provider time despite high volumes and large numbers of boarding patients. We created efficiencies that allowed us to maintain PUC LOS and PED door-to-provider times during the surge. This resulted in sustained improvement, and we now operate with shorter LOS and door-to-provider times than historically achieved.

How Super Is Supertrack? Expediting Care of Fast-track Patients through a Pediatric Emergency Department

Background

Fast-track models decrease patient crowding in emergency departments (EDs) by redirecting low-acuity patients to an expedited care pathway. In 2016, this institution's pediatric ED created a fast-track pathway for patients evaluated in a rapid assessment triage area who needed further management in the primary ED. This "Supertrack" designation was intended for patients requiring up to 1 hour of additional care, though means of ensuring these patients were discharged within their anticipated timeframe were lacking.

Methods

We aimed to increase the percentage of Supertrack patients discharged within 1 hour of their ED bed assignment from 17% to 50%. Interventions included the creation of objective Supertrack criteria, departmental-wide progress reports, personalized reminders, intake huddles, and documentation prompts. We visualized data from Plan, Do, Study, Act (PDSA) cycles with statistical process control charts to determine special cause variation.

Results

The percentage of Supertrack patients discharged within their anticipated timeframe increased from 17% to 27% without an increase in return ED visits. The average time Supertrack patients spent in the ED decreased from 121 to 103 minutes. Personalized reminders demonstrated a significant but short-lived improvement.

Conclusions

We improved the flow of Supertrack patients by decreasing their length of stay and increasing how many were discharged within their anticipated timeframe. Limitations included an unexpected surge in patients with respiratory complaints and staffing and structural constraints preventing the designation of a discrete Supertrack assessment space with dedicated providers. These findings are helpful for institutions seeking to develop an effective fast-track model with limited space and resources.

Causal Association of Physician-in-Triage with Improved Pediatric Sepsis Care: A Single-Center, Emergency Department Experience

Approximately 75,000 children are hospitalized for sepsis yearly in the United States, with 5%-20% mortality estimates. Outcomes are closely related to the timeliness of sepsis recognition and antibiotic administration.

Methods

A multidisciplinary sepsis task force formed in the Spring of 2020 aimed to assess and improve pediatric sepsis care in the pediatric emergency department (ED). The electronic medical record identified pediatric sepsis patients from September 2015 to July 2021. Data for time to sepsis recognition and antibiotic delivery were analyzed using statistical process control charts (X̄-S charts). We identified special cause variation, and Bradford-Hill Criteria guided multidisciplinary discussions to identify the most probable cause.

Results

In the fall of 2018, the average time from ED arrival to blood culture orders decreased by 1.1 hours, and the time from arrival to antibiotic administration decreased by 1.5 hours. After qualitative review, the task force hypothesized that initiation of attending-level pediatric physician-in-triage (P-PIT) as a part of ED triage was temporally associated with the observed improved sepsis care. P-PIT reduced the average time to the first provider exam by 14 minutes and introduced a process for physician evaluation before ED room assignment.

Conclusions

Timely assessment by an attending-level physician improves time to sepsis recognition and antibiotic delivery in children who present to the ED with sepsis. Implementing a P-PIT program with early attending-level physician evaluation is a potential strategy for other institutions.

Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A Comparative Observational Study

OBJECTIVES

Analyze the effectiveness of an intervention to reduce waiting time and patients leaving without being seen in the pediatric emergency department.

METHODS

A comparative observational study was carried out from November 2018 to April 2019.Patients aged 3 months to 17 years were included. The new organizational model consisted of a dedicated outpatients' clinic for nonurgent codes and a fast track for traumatic and surgical emergency cases.

RESULTS

The comparative group included 14,822, and the intervention group included 15,585 patients. The new organizational model significantly reduced the numbers of patients who left the ED without being seen from 12.9% to 5.9%.

CONCLUSIONS

This new organizational model in the pediatric emergency department could be successfully used to reduce overcrowding, waiting time, and the numbers of patients leaving without being seen. However, more needs to be done by the pediatric services in the community to reduce nonurgent accesses to the emergency department.

A framework to guide the implementation of lean management in emergency department

PURPOSE

The paper aims at enriching the knowledge of the application of lean management (LM) in emergency department (ED), structuring the methodology for implementing LM projects and summarizing the relevant dimensions of LM adoption in ED.

DESIGN/METHODOLOGY/APPROACH

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a systematic literature review has been performed, extracting a database of 34 papers. To answer the research purpose, a descriptive and content analyses have been carried out.

FINDINGS

The descriptive analysis demonstrates that the dealt topic is worldwide emerging and multidisciplinary as it arouses interest by medical and engineering communities. Despite the heterogeneity in the adopted methodology, a framework can be grasped from the literature review. It points out the phases and activities, the tools and techniques and the enablers to be considered for guiding the developing of LM project in ED.

ORIGINALITY/VALUE

This paper provides a comprehensive overview on how to adopt LM in ED, contributing to fill in the gap emerged in the literature. From a practical perspective, this paper provides healthcare managers with a synthesis of the best managerial practices and guidelines in developing a LM project in ED.