Sprint Team Approach Yields Rapid Improvement in Leapfrog Quality Indicators.

GOAL: Patient safety and quality care are two critical areas that every healthcare organization strives to grow and improve upon. At Scripps Health, specific efforts reviewed for this article were implemented to reduce hospital-acquired conditions and hospital readmissions that are components of Centers for Medicare & Medicaid Services programs and Leapfrog Hospital Survey scores. METHODS: Sprint teams, a novel approach to rapidly develop a checklist for lower-performing care improvement areas, were implemented after an internal review of existing tools and an evidence-based literature review. These areas included catheter-associated urinary tract infections (CAUTIs), central-line associated bloodstream infections (CLABSIs), Clostridioides difficile (C. diff.) and methicillin-resistant Staphylococcus aureus (MRSA) infections, chronic obstructive pulmonary disease (COPD) and heart failure readmissions, surgical site infections and handwashing, bar coding, and the computerized physician order entry components of Leapfrog scoring. The checklist for each area served as a teaching tool for staff and a guideline for case review to ensure that standard work was routinely performed. PRINCIPAL FINDINGS: The sprint teams showed dramatic results in the initial focus areas. From a baseline standardized infection ratio (SIR) of 1.141 for CLABSIs, the sprint team reduced the SIR to 0.885 in Year 1 of the program and to 0.687 in Year 2. For CAUTIs, the SIR decreased from a baseline of 1.391 in Year 1 to 0.720 in Year 2. C. diff. infections fell from 0.422 to 0.315 in Year 1 and to 0.260 in Year 2. While the MRSA SIR did not improve during the first year, the MRSA reduction sprint team showed success in Year 2 with a decrease in the SIR from 0.537 to 0.245. Readmission reduction sprint teams focused on heart failure, COPD, and total hip and knee complications. The teams also achieved positive results in reducing readmissions by following checklists and reviewing each readmission case for justification. PRACTICAL APPLICATIONS: Rapid change can be safely and effectively implemented with multidisciplinary sprint teams. Developed with an evidence-based, case review approach, sprint team checklists can help to standardize processes for the review of any infections or readmissions that occur in the inpatient arena.

Recovering Patient Trust We Lost in the Pandemic.

The question of how to engender patient trust in a pandemic is not easy to answer, and yet it is a critical question that requires a convincing response. On March 14, 2020, the surgeon general of the United States called for a stop to elective procedures. Ultimately, that led us at Scripps Health to close some clinics to protect personal protective equipment supplies and then furlough staff because of the decrease in patient visits. It soon became evident, however, that patients needed our care more than ever, and we had to pivot to provide the services they needed-but in a very different way. Our team rose to the challenge and quickly redesigned the entire organizational approach to accelerate telehealth services for the convenience of our patients. In the process, we also targeted a patient outreach program to our high-risk patients, which turned out to be an important aspect of our COVID-19 patient care initiative.

MD to MD Coaching: Improving Physician-Patient Experience Scores: What Works, What Doesn't.

With increasing national focus on patient experience scores through public reporting and the Value-Based Purchasing Program, hospitals and medical groups are challenged with initiating sustainable programs to improve their scores. Our system initiated 3 pilot programs to determine which approaches and techniques would be the most beneficial. The pilot trails included: (a) MD to MD 1:1 coaching with monthly MD-specific individual reports; (b) all staff patient experience training sessions at two of our urgent care centers; and (c) physician group patient experience training at one of our outpatient clinics. This article describes our 3 pilot initiatives and results that have been obtained.

Inpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department.

BACKGROUND: Emergency department (ED) discharge is safe when croup-related stridor has resolved after corticosteroids and a single dose of racemic epinephrine (RE). Little evidence supports the traditional practice of hospital admission after ≥ 2 doses of RE. OBJECTIVE: Our aim was to describe the frequency and timing of clinically important inpatient interventions after ≥ 2 ED RE doses. METHODS: We identified patients hospitalized for croup after ED treatment with corticosteroids and ≥2 doses of RE. We compared asymptomatic (admitted solely on the number of RE doses) and symptomatic (admitted due to disease severity) groups with regard to inpatient RE administration, supplemental oxygen, helium-oxygen mixture (heliox) therapy, intubation, or transfer to a higher level of care, time to hospital discharge, and revisit and readmission rates within 48 h of discharge. RESULTS: Of 200 subjects admitted after ≥ 2 ED RE doses, 72 (36%) received clinically important inpatient interventions: RE (n = 68 [34%]), heliox (n = 9 [5%]), and supplemental oxygen (n = 4 [2%]). Of patients who received inpatient RE, 53% received only 1 dose. No patients underwent intubation or transfer to higher level of care. The 112 asymptomatic patients had fewer interventions (14% vs. 63%; p < 0.001) and shorter hospital durations (14.5 vs. 22 h; p < 0.001). Only 14% of the asymptomatic group received RE, with 75% receiving a single dose. There were no differences in revisit and readmission rates. CONCLUSIONS: Inpatient interventions after ≥ 2 ED doses of RE for croup were infrequent, most commonly RE administration. Most patients asymptomatic upon admission require 0-1 inpatient RE doses and may be candidates for outpatient management.

Decreasing avoidable hospital admissions with the implementation of an emergency department case management program.

With the passage of the Affordable Care Act, increased emphasis has been placed on optimizing quality and reducing expenditures. The use of an emergency department case manager (EDCM) is reemerging as an important initiative in the quest to provide high-quality care and decrease unnecessary hospital admissions. A pilot study of the use of EDCMs was conducted in one of the authors' EDs during a 6-month trial period. By using evidence-based criteria, the EDCM helped in real time to verify admission criteria, assisted with inpatient versus outpatient designation, found community alternatives to hospital admission, and initiated discharge planning for patients who required admission and were at high risk for readmission. EDCMs also worked with pharmacists to assist with medication management for patients who required assistance with obtaining prescriptions. Because of the pilot study's success, the authors' health care system will be implementing EDCMs throughout the organization.

Improving emergency department time to provider, left-without-treatment rates, and average length of stay.

BACKGROUND: Emergency Department (ED) overcrowding and ensuing concern about patients who leave without treatment have become a mounting national concern. In addition, the Centers for Medicaid and Medicare Services released regulatory standards for EDs requiring reporting of time from initial triage to decision to admit, as well as actual time of admission. OBJECTIVES: To implement an improved ED patient flow process. METHODS: We performed a comparative, pre- and post-intervention ED redesign study evaluating three primary end points between two similar, seasonal time periods. RESULTS: Despite an 11% increase in daily patient volume in 2010, analysis of time to provider pre-ED redesign and post-ED redesign implementation revealed a mean of 126.7 min in 2009 (SD 37.03) vs. a mean of 26.3 min in 2010 (SD 1.17). The p-value was significant at <0.001. Overall ED average length of stay (ALOS) in 2009 was 5.5 h (SD 0.68) and 3.6 h (SD 1.16) in 2010, reflecting a mean reduction in ALOS of 1.9 h. The p-value was significant at <0.01. The proportion of patients who left without treatment (LWOT) also decreased. The proportion of LWOTs during the 2009 study period was 8.7% (95% confidence interval [CI] 6.14-11.26%), compared to 0.2% (95% CI 0.14-0.36%; p < 0.005) in the 2010 study period. Although the overall ED-visit Press Ganey patient-satisfaction scores improved during the 2010 study period, the results were not statistically significant (p < 0.1). CONCLUSION: Our study demonstrated that a tailored ED redesign process can dramatically decrease the time to provider, ALOS, and LWOT rates.

Rapid medical assessment: improving pediatric emergency department time to provider, length of stay, and left without being seen rates.

OBJECTIVES: This article aimed to study the impact of a rapid medical assessment (RMA) program on patient flow and left without being seen (LWBS) rates in a pediatric emergency department (ED). RMA is designed to evaluate and discharge uncomplicated patients quickly or initiate diagnostic workup and treatment before the patient is placed in an ED bed. METHODS: Rapid medical assessment was initiated January 1, 2008 with an assigned midlevel provider. We compared 6 months of data from January 1 to June 30, 2007 (pre-RMA), to January 1 to June 30, 2008 (post-RMA). Data studied were obtained from a tracking system and include the time to provider, ED length of stay, and the LWBS rate. t Test was used to compare results, and χ test was used to compare LWBS rates. RESULTS: During the study period, there were 28,360 patients seen in 2007 and 32,053 in 2008. Time to provider mean time was 80 minutes (median = 57) in 2007 and 53 minutes (median = 39) in 2008, with a difference of 27 minutes (95% confidence interval, 25-28 minutes). Mean length of stay in 2007 was 239 minutes (median = 220) compared to 181 minutes (median = 162) in 2008, with a difference of 58 minutes (95% confidence interval, 56-60 minutes). The LWBS rate decreased from 9% in 2007 to 3% in 2008 (χ P < 0.01). CONCLUSIONS: Rapid medical assessment is an effective way to improve patient flow and reduce the LWBS rate. A decrease in the LWBS rate allows the ED to provide health care to these potentially high-risk patients.

Afebrile pediatric seizures.

Most well-appearing children who have had an afebrile seizure can be managed as outpatients with instructions for an outpatient electroencephalogram and primary care physician follow-up. Laboratory studies are needed only in children younger than 6 months, in patients with prolonged seizures or altered level of consciousness, or in those with history of a metabolic disorder or dehydration. Emergent neuroimaging is not recommended in children with a first unprovoked afebrile seizure, although studies should be considered in children with a predisposing condition or focal seizures if younger than 3 years.

The management of children with gastroenteritis and dehydration in the emergency department.

BACKGROUND: Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE: To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION: The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS: In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Electrocardiographic manifestations: pediatric ECG.

Interpretation of pediatric electrocardiograms (ECGs) can be challenging for the Emergency Physician. Part of this difficulty arises from the fact that the normal ECG findings, including rate, rhythm, axis, intervals and morphology, change from the neonatal period through infancy, childhood, and adolescence. These changes occur as a result of the maturation of the myocardium and cardiovascular system with age. Along with these changes, up to 20% of pediatric ECGs obtained in the acute setting may have clinically significant abnormal findings. This article will discuss the approach to the interpretation of ECGs in children, the age-related findings and alterations on the normal pediatric ECG, and those ECG abnormalities associated with pediatric cardiac diseases, including the variety of congenital heart diseases seen in children.

Oral analgesia before pediatric ketamine sedation is not associated with an increased risk of emesis and other adverse events.

The objective of this study was to determine the association between recent administration of oral analgesics and frequency of adverse events during ketamine sedation in pediatric patients undergoing fracture reduction in the emergency department (ED). This retrospective study was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients aged

Ketamine-propofol combination sedation for fracture reduction in the pediatric emergency department.

OBJECTIVES: To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting. STUDY DESIGN: Prospective, observational pilot study. METHODS: Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review. RESULTS: Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred. CONCLUSIONS: In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.

Pediatric respiratory infections.

Pediatric respiratory infections are a common presenting complaint to the emergency department. This article discusses the presentation and management of infectious conditions, including bacterial tracheitis, bronchiolitis, croup, epiglottitis, pertussis, pneumonia, and retropharyngeal abscess.

Pediatric resuscitation update.

In 2005, the American Heart Association updated the guidelines for newborn and pediatric resuscitation. These changes are now being taught in the current Basic Life Support and Pediatric Advanced Life Support classes. This article reviews the pertinent new changes in caring for the critically ill child.

An update on the approach to apparent life-threatening events.

PURPOSE OF REVIEW: Apparent life-threatening events are an ongoing diagnostic dilemma for clinicians. Since most apparent life-threatening event episodes occur in infants under 6 months of age, they can generate considerable anxiety in parents and providers. This review will discuss issues to consider in the evaluation of infants after an apparent life-threatening event. To ensure proper management, a systematic approach should be taken to attempt to determine the cause of the event. RECENT FINDINGS: More recent literature suggests that infants with apparent life-threatening events frequently present without signs or symptoms of illness. Obtaining a careful history and physical examination is essential in determining the cause of the event. In this article, we will review the most current literature and discuss the American Academy of Pediatrics new recommendations on sudden infant death syndrome prevention. SUMMARY: After a careful review of the literature, prone sleeping is one of the biggest risk factors for sudden infant death syndrome. The association between apparent life-threatening events and sudden infant death syndrome remains to be explored further, but current evidence suggests minimal risk after an apparent life-threatening event episode. This article will help clinicians prepare for this difficult challenge by providing up-to-date information and identifying problems to be addressed in future research.

Seizures in children.

Seizures are the most common pediatric neurologic disorder. Four to ten percent of children suffer at least one seizure in the first 16 years of life. The incidence is highest in children less than 3 years of age, with a decreasing frequency in older children. Epidemiologic studies reveal that approximately 150,000 children will sustain a first-time unprovoked seizure each year, and of those, 30,000 will develop epilepsy. This article describes the types, diagnoses, and management and disposition of this pediatric neurologic disorder.

Newborn emergencies: the first 30 days of life.

The evaluation and appropriate management of the critically ill neonate requires knowledge of the physiologic changes and life-threatening pathologies that may present during this time period. A broad systematic approach to evaluating the neonate is necessary to provide a comprehensive yet specific differential diagnosis for a presenting complaint or symptom. Efficient recognition and prompt management of illness in the neonatal period may be life saving. Recently, it has become more important for the emergency department physician to be familiar with the neonate because of early discharge policies. This review provides a systematic approach to the recognition, emergency stabilization, and management of the more common newborn emergencies.

Pediatric dysrhythmias.

Arrhythmias in children are less common than in adults but are increasing because of successful repair of congenital heart diseases. Supraventricular tachycardia is the most common symptomatic pediatric tachyarrhythmia. Atrial flutter and atrial fibrillation in children are attributed largely to structural heart disease. Bradycardia is defined as a heart rate less than the lower limit of normal for a child's age, and the most common cause is sinus bradycardia. Despite the infrequent occurrence of arrhythmias, it is crucial to expeditiously identify and treat certain rhythm abnormalities because they can lead to further decompensation.