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

INTRODUCTION: Children's Hospital Colorado is an academic, tertiary-care Level 1 Trauma Center with an emergency department (ED) that treats >70,000 patients/year. Patient volumes continue to increase, leading to worsening wait times and left-without-being-seen (LWBS) rates. In 2015, the ED's median door-to-provider time was 49 minutes [interquartile range (IQR) = 26-90], with a 3.2% LWBS rate. ED leadership, staff, and providers aimed to improve patient flow with specific goals to (1) decrease door-to-provider times to a median of <30 minutes and (2) decrease annual LWBS rate to <1%. METHODS: An inter-professional team utilized quality improvement and Lean methodology to study, redesign, and implement significant changes to ED front-end processes. Key process elements included (1) new Flow Nurse/EMT roles, (2) elimination of traditional registration and triage processes, (3) immediate "quick registration" and nurse assessment upon walk-in, (4) direct-bedding of patients, and (5) a novel "Intake" system staffed by a pediatric emergency medicine physician. RESULTS: In the 12 months following full implementation of the new front-end system, the median door-to-provider time decreased 49% to 25 minutes (IQR = 13-50), and the LWBS rate decreased from 3.2% to 1.4% (a 56% relative decrease). Additionally, the percentage of patients seen within 30 minutes of arrival increased, overall ED length-of-stay decreased, patient satisfaction improved, and no worsening of the unexpected 72-hour return rate occurred. CONCLUSIONS: Using quality improvement and Lean methodology, an inter-professional team decreased door-to-provider times and LWBS rates in a large pediatric ED by redesigning its front-end processes and implementing a novel pediatric emergency medicine-led Intake system.

Seventy-two-hour Return Initiative: Improving Emergency Department Discharge to Decrease Returns.

Unscheduled return visits within 72 hours of discharge account for 4% of pediatric emergency department (ED) visits each year and are a quality indicator of ED care. This project aimed to reduce the unexpected 72-hour return visit rate for a network of ED and urgent cares (UC) by improving discharge processes. METHODS: A multidisciplinary team conducted a quality improvement initiative in the EDs/UCs of a tertiary children's hospital network. The team developed discharge interventions through successive Plan-Do-Study-Act cycles. They included standardization of the electronic health record discharge workflow and implementation of "mini-after care instructions" and teach-back education. The team used a statistical process control chart to follow the 72-hour return rate, and a chi-square test to compare the pre- and post-intervention 72-hour return rate. RESULTS: The ED/UC network discharged 219,196 patients during the study, 12/2014-4/2016. The baseline 72-hour return rate was 3.5% before interventions. The team implemented discharge interventions from 12/14 to 9/15. After the implementation of mini-after care instructions (4/15), 8 consecutive points fell below the mean on the statistical process control chart, and there was an 8.2% reduction in the 72-hour return rate (P < 0.01). Admission rates of 72-hour return patients remained stable throughout the study (27% pre-intervention and 28% post-intervention). Improvements to the ED/UC discharge process resulted in the estimated prevention of 600 ED/UC visits annually throughout the network. CONCLUSIONS: Quality improvement methodology and multidisciplinary enhancement of discharge processes significantly decreased 72-hour return rates across a network of pediatric EDs and UCs.

The Caregiver Perspective on Unscheduled 72-Hour Return Visits to Pediatric Acute Care Sites: A Focus on Discharge Processes.

OBJECTIVE: To characterize pediatric caregivers' reasons for 72-hour emergency department (ED) and urgent care (UC) returns. METHODS: A sample of caregivers returning within 72 hours of initial visit to a pediatric ED or affiliated UC site was surveyed from November 2014 to June 2015; patients evaluated at outside ED/UC, scheduled for return, or non-English/Spanish speaking were excluded. Caregiver surveys underwent item generation, validation, and pilot testing. Survey items included caregiver reasons for unscheduled returns, with a specific assessment of delivery of key components of discharge instructions (diagnosis, duration of illness, home care, return precautions). Complete delivery of instructions was defined by caregiver reported receipt of instructions on all 4 components. RESULTS: Of the 500 caregiver surveys analyzed 495 children received a 72-hour return ED/UC visit. Mean age of caregivers was 33 years, 62% completed college. Children were 2 years of age or younger (47%), male (52%), Caucasian (55%), and publicly insured (64%). Reported reasons for ED/UC return included belief that their child's illness had not resolved (51%) or worsened (41%). Many caregivers (41%) were not instructed on all key components of discharge. Almost half of caregivers (47%) were not educated on anticipated duration of illness. Complete delivery of discharge instructions was associated with ED/UC satisfaction (odds ratio, 5.7; 95% confidence interval, 3.8-8.5). CONCLUSIONS: Among caregivers of children returning for an unscheduled ED/UC visit, most do not receive complete discharge instructions at initial visit. Improving delivery of key components of discharge instructions has the potential to increase ED/UC satisfaction and reduce unscheduled 72-hour returns.

Limited Abdominal Sonography for Evaluation of Children With Right Lower Quadrant Pain.

OBJECTIVES: To determine whether a complete abdominal sonographic examination is necessary in the evaluation of children with right lower quadrant pain that is suspicious for appendicitis in the emergency department and whether performing a limited, more-focused study would miss clinically important disease. METHODS: With Institutional Review Board approval, a retrospective study was performed of 704 patients, from ages 5-19 years, presenting to the emergency department with right lower quadrant pain that was suspicious for appendicitis who underwent a complete abdominal sonographic examination. Data were extracted from the complete abdominal sonographic examination to see whether abnormalities were noted in the pancreas, spleen, and left kidney. Patients' medical charts were reviewed to see whether any positive findings in these organs were clinically important. RESULTS: Of the 65 studies with a finding that would have been missed with a limited study, only 6 were found to be clinically important. Of those, 5 were managed medically and 1 surgically. The chance of missing a potentially important finding using a limited study with our group of patients was 65 of 704 patients (9.2%), with a 95% confidence interval of 7.2% to 11.7%. The chance of missing an abnormality that was clinically important was 6 of 704 patients (0.85%), with a 95% confidence interval of 0.35% to 1.94%. CONCLUSIONS: In children older than 5 years with abdominal pain that is suspicious for appendicitis, performing only a limited abdominal sonographic examination that excludes the pancreas, left kidney, and spleen will yield a miss rate for clinically important disease that is acceptably low to justify the savings of examination time.

Mobile pediatric emergency response team: patient satisfaction during the novel H1N1 influenza outbreak.

OBJECTIVES: The objective was to determine child caregiver satisfaction with a nontraditional pediatric emergency department (ED) venue during the 2009 novel H1N1 influenza outbreak. METHODS: Between May 1 and 7, 2009, the Texas Children's Hospital (TCH) ED used a six-bed outdoor facility, the Mobile Pediatric Emergency Response Team (MPERT), to evaluate patients with suspected novel H1N1 influenza. Parents and caregivers of patients evaluated in the MPERT were surveyed by telephone using a validated questionnaire to evaluate satisfaction with the facility. RESULTS: Of 353 patients, 155 caregivers (44%) completed questionnaires; 127 had wrong numbers, 71 did not answer, and 15 were on a no-call list. Survey responders felt that nurses and doctors explained concepts well (nurses 92%, doctors 94%), 91% felt TCH prepared them well for taking care of their children at home, 94% were satisfied with the medical care received, and 88% were not bothered by the outdoor setting. When asked to rate their MPERT experience on a scale of 0 (worst possible) to 10 (best possible), the median score was 9 (range 1 to 10). CONCLUSIONS: The MPERT facility alleviated patient volume surge and potentially prevented transmission during H1N1 outbreak. While these were health care provider goals, caregiver expectations were also met. Caregivers perceived MPERT as an acceptable alternative to receiving care in the regular ED, felt that physicians and nurses communicated well, and felt that medical care was good to excellent. Use of the MPERT did not negatively affect overall caregiver satisfaction with TCH. These findings suggest that families of pediatric patients are amenable to nontraditional ED venues during periods of ED crowding.

Outside the box and into thick air: implementation of an exterior mobile pediatric emergency response team for North American H1N1 (swine) influenza virus in Houston, Texas.

STUDY OBJECTIVE: We describe the implementation of a mobile pediatric emergency response team for mildly ill children with influenza-like illnesses during the H1N1 swine influenza outbreak. METHODS: This was a descriptive quality improvement study conducted in the Texas Children's Hospital (Houston, TX) pediatric emergency department (ED), covered, open-air parking lot from May 1, 2009, to May 7, 2009. Children aged 18 years or younger were screened for viral respiratory symptoms and sent to designated areas of the ED according to level of acuity, possibility of influenza-like illness, and the anticipated need for laboratory evaluation. RESULTS: The mobile pediatric emergency response team experienced 18% of the total ED volume, or a median of 48 patients daily, peaking at 83 patients treated on May 3, 2009. Although few children had positive rapid influenza assay results and the morbidity of disease in the community appeared to be minimal for the majority of children, anxiety about pandemic influenza drove a large number of ED visits, necessitating an increase in surge capacity. Surge capacity was augmented both through utilization of existing institutional resources and by creating a novel area in which to treat patients with potential airborne pathogens. Infection control procedures and patient safety were also maximized through patient cohorting and adaptation of social distancing measures to the ED setting. CONCLUSION: The mobile pediatric emergency response team and screening and triage algorithms were able to safely and effectively identify a group of low-acuity patients who could be rapidly evaluated and discharged, alleviating ED volume and potentially preventing transmission of H1N1 influenza.