Optimizing Critical Care Documentation in a Pediatric Emergency Department

Area of Science:

• Healthcare Management
• Quality Improvement in Medicine
• Emergency Medicine

Background:

• Emergency department (ED) physicians often provide critical care (CC) but face documentation inconsistencies.
• Inconsistent CC documentation can lead to underbilling and financial inefficiencies, impacting hospital revenue.
• At baseline, only 20% of eligible visits had correct CC notes, representing an estimated $1.8 million in potential annual missed charges.

Purpose of the Study:

• To increase the placement of CC notes for eligible patients from a baseline of 20% to 60% within a 2-year timeframe.
• To measure the impact of interventions on CC note completion rates and intensive care unit (ICU) admissions.
• To assess changes in facility fees associated with improved CC documentation.

Main Methods:

• A quality improvement project was conducted at a midwestern quaternary children's hospital with 120,000 annual ED visits.
• Interventions included simplifying CC notes, providing education, conducting follow-up surveys, optimizing note location, and implementing timely reminders, guided by plan-do-study-act cycles.
• Data analysis involved chart reviews and statistical methods including χ2 tests and control charts.

Main Results:

• CC note placement for ICU admissions rapidly increased from 20% to 60% within 8 months, eventually exceeding 75%.
• The rate of CC notes per 1000 ED visits rose from 4 to 16, with a corresponding increase in ICU admissions that remained appropriate.
• Billed facility fees for CC services saw a substantial increase of 263%.

Conclusions:

• The project successfully achieved significant and sustained improvements in CC note completion rates.
• Key factors contributing to success included targeted education, streamlined documentation processes, automated reminders, and financial incentives.
• These strategies demonstrate a viable approach to enhancing documentation accuracy and financial performance in critical care settings.