Redirecting Nonurgent Patients From the Pediatric Emergency Department to Their Pediatrician Office for a Same-Day Visit-A Quality Improvement Initiative.

OBJECTIVES: Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMART AIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period. METHODS: The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED. RESULTS: The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients. CONCLUSIONS: This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.

The educational experience of pediatric emergency medicine fellows in the use and application of procedural sedation/analgesia.

OBJECTIVES: The purpose of this study is to describe the clinical and educational experience provided to the pediatric emergency medicine (PEM) fellows in procedural sedation/analgesia during their course of training. METHODS: A nonanonymous survey was completed by the program director of each Accreditation Council for Graduate Medical Education (ACGME)-accredited PEM fellowship program listed in the 2001 to 2002 Graduate Medical Education Directory. Information relating to program demographics, agents available for use in the emergency department (ED), and the educational opportunities offered to trainees was sought. RESULTS: Each of the 32 ACGME-accredited programs completed the survey. Thirty programs report using procedural sedation and analgesia (PSA) to facilitate the completion of nonpainful and 32 programs to facilitate the completion of painful procedures in the ED. Twenty-nine programs (92%) permit their fellows to provide PSA independently after meeting credentialing criteria at their institution. Formal didactic sessions, direct supervision of procedures, and dedicated journal clubs were the 3 most frequently cited educational methods reported. The educational method chosen was not predicted by the ED type, the size of the training program, or by the volume of patients evaluated in the ED. Twelve program directors report their belief that a minimum number of procedures should be completed prior to completion of the training program. CONCLUSION: There is wide variation in the educational methods used by PEM fellowship training programs in procedural sedation/analgesia.