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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
Standardization of Discharge Instructions by Age for Children Presenting to the ED With Mild Traumatic Brain Injury:
Niralee K Rana1, Nicole L Gerber2, Snezana Nena Osorio3
1Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ.
Insights
Pediatric emergency departments improved age-appropriate discharge instructions for mild traumatic brain injuries (mTBI) using electronic medical record smart phrases. This quality improvement initiative enhanced patient care and reduced parental anxiety.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement Science
- Traumatic Brain Injury Management
Background:
- Mild traumatic brain injuries (mTBI) are frequent in pediatric emergency departments (EDs).
- Inconsistent diagnostic labels and discharge instructions for mTBI, particularly concussions, lead to increased parental anxiety and ED revisits.
- Lack of age-appropriate guidance hinders recovery for pediatric patients with mTBI.
Purpose of the Study:
- To increase the proportion of pediatric mTBI patients receiving age-appropriate discharge instructions to 50% within 13 months in an urban pediatric ED.
- To implement and evaluate standardized, age-specific discharge instructions for pediatric mild traumatic brain injuries.
- To reduce parental anxiety and improve post-discharge outcomes for children with mTBI.
Main Methods:
- An interdisciplinary quality improvement team conducted an observational time series study using Plan-Do-Study-Act (PDSA) cycles over 13 months.
- Interventions included an educational curriculum, e-reminders, workspace materials, and electronic medical record (EMR) smart phrases for age-specific discharge instructions.
- Data were analyzed using process control charts, with parent surveys assessing knowledge, behavior, and anxiety post-discharge.
Main Results:
- Age-appropriate discharge instruction rates improved from 36% to 56% among 1263 pediatric mTBI patients.
- EMR smart phrases were utilized in 58% of relevant cases, with no significant changes in CT utilization, ED revisits, or neurology referrals.
- Among surveyed parents, 95% found instructions helpful, and 68% reported reduced anxiety.
Conclusions:
- Implementation of EMR smart phrases successfully increased standardized, age-appropriate discharge instructions for pediatric mTBI.
- These low-cost interventions are scalable and effective for improving care in pediatric EDs and other settings.
- Standardized discharge instructions positively impact parental understanding and reduce anxiety following pediatric mTBI.
Introduction:
Mild traumatic brain injuries (mTBI) are common in pediatric emergency departments (EDs), but inconsistent use of diagnostic labels leads to variable discharge instructions, especially with regard to concussion. Lack of age-appropriate guidance can increase parental anxiety and ED revisits and hinder recovery.
Objective:
This quality improvement (QI) initiative aimed to increase the proportion of mTBI patients receiving age-appropriate discharge instructions to 50% over 13 months in an urban pediatric ED.
Methods:
An interdisciplinary QI team conducted an observational time series study with sequential experimentation at a quaternary academic medical center over 13 months. Using a key driver diagram, they created SMART aim, measures, and designed interventions which were tested through 5 Plan-Do-Study-Act (PDSA) cycles. Interventions included an educational curriculum, e-reminders, workspace materials, and pre-written electronic medical record (EMR) templates (smart phrases) for age-specific discharge instructions (0 to 5 y, ≥6 y), and parent surveys were used on a subset of sample families to assess knowledge, behavior, and anxiety post-discharge. Outcome measures included the percentage of age-appropriate discharge instructions provided and use of the new EMR smart phrase. Balancing measures tracked head computed tomography (CT) utilization, ED revisits within 14 days of discharge, and neurology referrals. Process control charts and rules to detect special cause variation were used to analyze data. We use descriptive statistics to analyze survey data.
Results:
Among 1263 patients, age-appropriate discharge instruction rates improved from 36% to 56%. Smart phrases were used in 58% of relevant cases (n=628). No changes were observed in CT orders, ED revisits, or neurology referrals. Among 37 surveyed parents (28% response rate), 95% (n=35) found instructions helpful, and 68% (n=25) reported reduced anxiety.
Conclusions:
Implementing EMR smart phrases in a pediatric ED increased standardized, age-appropriate discharge instructions for children with mTBI. These low-cost interventions are scalable for broader ED use and other settings.
