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Improving the Safety of an Emergency Department-Based Direct Admission Process at a Children's Hospital
Tess Huy1, Lia Lowrie, Robert Flood
1From the Department of Pediatrics, Divisions of General Academic Pediatrics and Pediatric Emergency Medicine for Saint Louis University.
Insights
Implementing a screening protocol for direct admissions significantly reduced transfers to the pediatric intensive care unit (PICU). This quality improvement initiative enhanced patient safety by ensuring appropriate initial patient placement.
Area of Science:
- Quality Improvement
- Patient Safety
- Pediatric Critical Care
Background:
- Direct admissions bypass traditional emergency department entry, increasing risks of inappropriate patient placement.
- Inappropriate direct admissions can lead to adverse events like rapid response activations and transfers to the pediatric intensive care unit (PICU), impacting patient outcomes.
Purpose of the Study:
- To enhance the safety of the direct admission process.
- To decrease the rate of direct admission patients transferred to the PICU within 6 hours of arrival.
Main Methods:
- A multidisciplinary team utilized the Model for Improvement and Plan-Do-Study-Act cycles.
- Implemented a screening process in the emergency department including vital signs and Pediatric Early Warning Score.
- Focused on role definition, documentation, awareness, visual management, and education for EMS and transport providers.
Main Results:
- Over 3000 direct admissions were analyzed from January 2014 to June 2018.
- Screening protocol compliance increased from 56% to over 80%.
- Unanticipated direct admission-to-PICU transfers decreased from 1 in 98 patients to 1 in 1126 patients.
Conclusions:
- Quality improvement methodology successfully improved the direct admission process.
- The implemented screening process was consistent, easier to document, and enhanced patient safety.
- Reliable screening of direct admissions effectively reduces transfers to higher levels of care.
Objectives:
Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours.
Methods:
Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures.
Results:
The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients.
Conclusions:
By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.
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