Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital.

INTRODUCTION: An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years. METHODS: A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes. RESULTS: Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %). DISCUSSION: Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

Use of Lean Healthcare to Improve Hospital Throughput and Reduce LOS.

Improving the discharge process is an area of focus throughout healthcare organizations. Capacity constraints, efficiency improvement, patient safety, and quality care are driving forces for many discharge process workgroups. METHODS: Following the Pareto principle, we focused on improving the discharge process on the medical-surgical units that received the most patients admitted from the emergency department. Increased demand for medical-surgical beds, renovations, and diminished bed capacity made it imperative to improve efficiency using quality improvement techniques. A core team of frontline staff decreased the time between computer entry of discharge orders and patient's departure from the unit to less than 60 minutes, with 80% compliance. The team developed a daily dashboard that detailed the process and outcome measures to create situational awareness and daily visual management. Additional observations of staff workflow uncovered excessive walking for printer use. Printers were placed at the point of use to reduce transport times. Next, using survey results provided by patients on discharge quality, a Treasure Map that aided with teach-back and Team Discharge were implemented to level the staff's workload. Finally, physicians discharged patients earlier in the day. They standardized their discharge criteria to remove subjectivity from the discharge process and enable better team involvement. RESULTS: After implementing 4 interventions, the average time between computer entry of discharge orders and patient's departure from the unit decreased (94.26 versus 65.98 minutes; P < 0.001), simultaneously reducing our average length of stay from 5.62 to 4.81 days (P < 0.001). CONCLUSIONS: In conclusion, hardwiring proven interventions and complementing them with daily visual management led to significant, sustained results.

A Comprehensive Survey of Institutional Patient/Family Educational Practices for Newly Diagnosed Pediatric Oncology Patients.

Patient/family education is an important component of nursing practice and is essential to the care of children newly diagnosed with cancer. Practices regarding patient/family education in Children's Oncology Group (COG) treatment centers have not been well described. We used an Internet-based survey to determine current patient/family educational practices at COG institutions; participation rate was 90.5% (201/222). Patient/family education was delivered primarily by an individual (rather than a team) at 43% of institutions. Advanced practice nurses had primary responsibility for providing education at 32% of institutions. "Fever" was the most frequently reported topic considered mandatory for inclusion in education for newly diagnosed patients. More than half of institutions reported using checklists and/or end-of-shift reports to facilitate health care team communication regarding patient/family education, and 77% reported using the "teach-back" method of assessing readiness for discharge. Thirty-seven percent of institutions reported delays in hospital discharge secondary to the need for additional teaching. An understanding of current practices related to patient/family education is the first step in establishing effective interventions to improve and standardize educational practices in pediatric oncology.