Improving Throughput for Mid-acuity Patients in the Pediatric Emergency Department.

PURPOSE: Visits to pediatric emergency departments (EDs) are increasing, leading to overcrowding, prolonged patient wait times, and negative patient experiences. In our system, these prolonged wait times and negative experiences notably impact mid-acuity patients. As such, we sought to decrease their time-to-first-provider from 92 to 60 minutes. METHODS: After identifying inefficiencies in patient arrival, triage, and assessment, we redesigned our physical space and implemented a new triage process. Further, we deployed a new multidisciplinary front-end team consisting of a physician, nurses, and ED tech specialists to create and implement an initial management plan. Time-to-first-provider for mid-acuity patients was the main outcome measure. We examined ED length of stay (LOS) as a balancing measure. Post hoc, we measured time-to-first-nursing assessment and the proportion of high-acuity patients seen within 20 minutes as additional measures of the impact of these interventions on our system. All analyses were measured using statistical process control charts. RESULTS: During high patient volumes, we decreased the time-to-first-provider to 70 minutes, but exceeded our goal during low patient volumes (41 minutes). We observed a 5% decrease in LOS during both high and low patient volumes (5% and 8%, respectively). There was a 60% increase in the time-to-first-nursing assessment. CONCLUSIONS: A new front-end process resulted in improved time-to-first-provider and LOS. The new process was associated with longer times for nursing assessments but did not negatively impact the rapid physician assessment of higher acuity patients.

Decreasing Blood Culture Contaminants in a Pediatric Emergency Department: An Interrupted Time Series Analysis.

INTRODUCTION: High peripheral blood culture contamination rates (BCCR) in the emergency department (ED) contribute to overuse and harm. This study describes 2 years of quality improvement (QI) interventions that aimed to decrease a high BCCR in a pediatric ED. METHODS: The QI team created a Key Driver Diagram with multiple Plan-Do-Study-Act (PDSA) cycles. PDSA interventions included a venipuncture sterility checklist (PDSA1), phlebotomist feedback system (PDSA2), and physician ordering guidelines (PDSA3). The specific aim was to decrease the BCCR by 50% within 24 months. The secondary aim was to decrease the peripheral blood culture ordering rate (BCOR) by 10% within 24 months. The balancing measure was the proportion of pathogenic bacteremia cases at ED return visits before and after PDSA3 implementation. A financial measure estimated the savings in charges between the observed and expected contaminants in PDSA3. An interrupted time series design applied statistical process control methodology to detect special cause variations. RESULTS: The BCCR in the baseline, PDSA1, PDSA2, and PDSA3 periods were 3.02%, 2.30%, 1.58%, and 1.17%, respectively. The BCOR in the baseline, PDSA1, PDSA2, and PDSA3 periods was 4.80%, 4.26%, 3.82%, and 3.49%, respectively. Special cause variations occurred after PDSA cycle implementations for both BCCR and BCOR. There was no change in the balancing measure. The interventions were associated with an annual prevention of 95 contaminants and savings of $300,070. CONCLUSIONS: Interventions that focused on improving venipuncture technique and limiting unnecessary blood cultures were associated with fewer contaminants and the achievement of the QI team's project aims.

Caring in pediatric emergency nursing.

An environment committed to providing family-centered care to children must be aware of the nurse caring behaviors important to parents of children. This descriptive study assessed the psychometrics of a revised version of the Caring Behaviors Assessment (CBA) and examined nurse caring behaviors identified as important to the parents of pediatric patients in a pediatric emergency department. Jean Watson's theory of human caring provided the study's theoretical underpinnings. The instrument psychometrics was determined through an index of content validity (CVI) and internal consistency reliability. The instrument was determined to be valid (CVI = 3.75) and reliable (Cronbach's alpha = .971). The revised instrument was completed by a stratified, systematic random sample of 300 parents of pediatric emergency patients. Participants rated the importance of each item for making the child feel cared for by nurses. Individual survey item means were computed. Items with the highest means represented the most important nurse caring behaviors. Leading nurse caring behaviors centered on carative factors of "human needs assistance" and "sensitivity to self and others." Nearly all nurse caring behaviors were important to the parents of pediatric patients, although some behaviors were not priority. It is important for nurses to provide family-centered care in a way that demonstrates nurse caring.