Best Practices for Improving Flow and Care of Pediatric ... · pediatric care, deﬁning pediatric emergency care competencies as well as the requirement to achieve and maintain these

TECHNICAL REPORT

Best Practices for Improving Flow andCare of Pediatric Patients in theEmergency DepartmentIsabel Barata MD Kathleen M Brown MD Laura Fitzmaurice MD Elizabeth Stone Griffin RN Sally K Snow BSN RNAmerican Academy of Pediatrics Committee on Pediatric Emergency Medicine American College ofEmergency Physicians Pediatric Emergency Medicine Committee Emergency Nurses Association Pediatric Committee

abstractThis report provides a summary of best practices for improving flow reducingwaiting times and improving the quality of care of pediatric patients in theemergency department

CURRENT STATUS AND NEEDS

ED Use and ED Crowding in the UnitedStates

Approximately 800 000 children seek care in the emergency department(ED) each day in the United States Additionally it is estimated that 34of US children use EDs as their source for sick care The vast majority(92) of these children are seen in community EDs with a smallerpercentage seen in pediatric EDs The increase in ED utilization hassaturated the capacity of EDs and emergency medical services in manycommunities Increases in patient volume and decreases in resourcesincluding fragmentation of resources and shortage of criticalsubspecialists have resulted in EDs facing crowding and ambulancediversion

The need for emergency medical services outstrips the available resourceson a daily basis This mismatch is reflected by the considerable increase inthe number of patients visiting EDs In 1993 903 million patients visitedEDs in 2003 that number increased to 1139 million patientsApproximately 21 of these patients were younger than 15 years Despitethe increase in ED visits the number of hospitals decreased by 703 thenumber of hospital beds decreased by 198 000 and the number of EDsdecreased by 42512 More recent data indicate that this trend continuedbetween 2001 and 2008 the number of ED visits increased by 19 peryear (95 confidence interval [CI] 12ndash25) a rate 60 faster thanpopulation growth Mean occupancy defined as the number of patients inan ED at a single point in time divided by the number of standard

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors All authors have filedconflict of interest statements with the American Academy ofPediatrics Any conflicts have been resolved through a processapproved by the Board of Directors The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care Variations takinginto account individual circumstances may be appropriate

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers However technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmedrevised or retired at or before that time

wwwpediatricsorgcgidoi101542peds2014-3425

DOI 101542peds2014-3425

Accepted for publication Oct 24 2014

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2015 by the American Academy of Pediatrics

PEDIATRICS Volume 135 number 1 January 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 15 2020wwwaappublicationsorgnewsDownloaded from

treatment spaces increased evenmore rapidly at 31 per year3

The Effect of Crowding on Safety andQuality of Pediatric Emergency Careand Throughput

ED crowding threatens patient safetyincreases medical errors prolongslength of stay decreases patientsatisfaction and jeopardizes thereliability and ability of the US healthcare system to effectively care forpatients4ndash6 Specific examples of theeffects of ED crowding on quality ofED care including timeliness of careand patient safety have beenpublished

Studies have shown an associationbetween ED crowding andthroughput measures such as lengthof stay in EDs7 In a large urbanchildrenrsquos hospital ED boarding timeand ED daily census showedindependent associations withincreasing overall length of stay timeto triage time until seen by physicianand number of patient elopements(ie patients leaving without beingseen by a physician or leaving beforetreatment is initiated)8 Anotherstudy of 4 general EDs showed anassociation between measures ofcrowding and timeliness ofemergency care The delays affectedeven the patients with highest acuityDuring crowded periods (ie 90higher than the average census) theadjusted median waiting room timesof high-acuity level 2 patientsaccording to the 5-level EmergencySeverity Index were 3 to 35higher than during normal periods9

The percentage of patients in the EDwho are seen by a physician withinthe time recommended by triageclassification has been steadilydeclining and is at its lowest point inat least 10 years Of all the patienttriage levels in the ED the moreurgent patients are the least likely tobe seen within the triage target timePatients of all racialethnicbackgrounds and payer types havebeen similarly affected10 EDcrowding has also been shown to be

associated with an increase in therate of patients who leave withoutbeing seen by a provider11 Otherstudies have revealed that waitingtime to see an ED provider was longerat hospitals in poorer neighborhoods12

These studies show that ED crowdingmay be associated with deficits inboth the timeliness and equitability ofpatient care

Other domains of the quality of EDcare may also be affected by poor EDthroughput and crowding In a studyin pediatric ED patients experiencingan acute asthma exacerbationtimeliness and effectiveness qualitymeasures demonstrated an inversedose-related association withoccupancy and time to see anattending physician Patients were52 to 74 less likely to receivetimely care and were 9 to 14 lesslikely to receive effective care whenthe crowding measures were at the75th rather than at the 25thpercentile (P 05)13

Crowding was also associated withdelay in analgesic administration inpediatric patients with sickle cell paincrisis in a pediatric ED14 EDcrowding has also been associatedwith delay of and failure toadminister antibiotics for adultpatients admitted with community-acquired pneumonia1516 and withdelays in analgesic treatment inpatients presenting with acuteabdominal pain17 Other studies haveshown similar associations betweenED crowding and quality of care inadult ED patients including thetreatment of patients with pain1518

ED crowding is also associated withdeficits in patient safety A studyconducted in 4 general-populationEDs showed an association betweenED crowding and preventable medicalerrors19 Other investigators havealso found an association betweenED crowding measures in an adultand pediatric ED population andmedication errors20 More recentlySun et al21 demonstrated anassociation between ED crowding and

mortality hospital length of stay andcosts in 187 California hospitals Theestimate of the costs attributable toED crowding was 300 additionalinpatient deaths 6200 excess hospitaldays and $17 million in adult EDadmissions ED crowding andincreased wait times are associatedwith decreased patient satisfactionwith ED care2223 One studycompleted in 5 general teachinghospital EDs revealed that not feelinginformed about prolonged waits inadult patients was associated withgreater dissatisfaction (odds ratio[OR] 048 95 CI 039ndash057)24

Another study revealed that ED waittimes correlated with patientsrsquosatisfaction with both their ED andinpatient care25 A study in pediatricED patients showed that both parentand child satisfaction was correlatedwith wait time This study also foundthat timely resolution of pain wasimportant to both parents andchildren26 There is also evidencefrom studies in both adults andchildren that improvement in ED waittimes leads to improved patientsatisfaction2728

In summary ED crowding isa growing problem and is associatedwith increased lengths of stay in theED increased patient elopementrates and significant deficits in thequality of care domains of safety andtimeliness29 ED crowding has alsobeen linked to deficits in patientsatisfaction and the quality domainsof efficiency and equitabilityImproving ED throughput andrelieving ED crowding is an essentialcomponent of improving the qualityof ED care

Calls to Improve ED Crowding andDelivery of Care

Regulators and payers have begun torecognize and address this problemThe Joint Commission views patientflow in the ED as a patient safetyissue specifically targeting patientboarding of psychiatric patients30 In2014 the Centers for Medicare andMedicaid Services began requiring

e274 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on March 15 2020wwwaappublicationsorgnewsDownloaded from

that hospitals report 5 ED crowdingmeasures31 including median timefrom ED arrival to ED departure fordischarged patients door-to-diagnostic evaluation by a qualifiedmedical professional patients wholeave before being seen median timefrom ED arrival to ED departure foradmitted patients and median timefrom admit decision time to time ofdeparture for admitted patientsWhile instituting processimprovements for flow andefficiency quality patient careneeds to be the driving force TheInstitute of Medicine (IOM) haschallenged pediatric providers ofemergency care as well as businesscoalitions government and privateindividual purchasers andemployees3233 to provide objectiveevidence that they are receivinghigh-quality health care services forthe price paid34

In the IOM report Emergency Care forChildren Growing Pains a challengewas made to providers of pediatricemergency care by asking formethods to improve ED flow reduceED waits and establish a highstandard for pediatric emergencycare The 3 main goals for thisimproved delivery of care includedthe following coordination (to allowldquothe most appropriate care at theoptimal location with the minimumdelayrdquo) regionalization (to developevidence-based categorizationsystems for emergency medicalservices EDs and trauma centers)and accountability (the creation ofevidence-based indicators ofemergency and trauma care systemperformance measures including theperformance of pediatric emergencycare) Specific challenges for pediatricemergency medicine includeexpanding and strengthening thepediatric workforce to enhancepediatric care defining pediatricemergency care competencies as wellas the requirement to achieve andmaintain these competenciesupdating clinical guidelines andstandards of care and developing

strategies for addressing pediatricneeds in the event of a disaster35

Clinical Practice Pathways

Clinical pathways aremultidisciplinary plans of carestructured and designed to supportthe implementation of clinicalguidelines and protocols for ED careand can be used to treat high-volumeor high-risk pediatric patients Theuse of these nurse-initiated clinicalpathways does not suggest that suchclinical care is the only appropriatecourse of treatment The use ofevidence-based nurse-initiatedstanding ordersprotocols issupported by the Centers forMedicare and Medicaid Services asa method by which to enhance thequality and efficiency of patientcare36 These nurse-initiated clinicalpathways are not intended as a proxyfor standard of care Rather they areintended and have been proven toincrease efficiency decreasevariation and minimize risk forpediatric patients37ndash41 A study ofmore than 15 000 adult patients from1 urban ED revealed that nurse-initiated triage diagnostic standingorders were associated with a 16reduction in the time of in-room EDcare42 Commonly used examples ofclinical pathways include those forasthma bronchiolitis dehydrationand fever in the neonate Because ofthe unique risks related to theboarding of behavioral healthpatients clinical pathways thatinclude the utilization of a nursepractitioner to support their care is1 example of how hospitals canaddress the medical and safety needsinherent to this population43 Suchcollaboration would also helphospitals meet the 20132014guidelines from the Joint Commissionin caring for these patients44

Many insurers are determiningbenchmarks for defining quality careand are instituting paymentincentives for reaching thesebenchmarks45 Unfortunately severalof these benchmarks do not seem to

be appropriate when systematicallyreviewed46 More recently providersof pediatric emergency care havebeen more proactive in addressingthe issue of what determines qualitypediatric emergency care47ndash51

The 2001 IOM report Crossing theQuality Chasm emphasized thatevidence-based practice should bea combination of the best researchclinical expertise and patient valuesPractice guidelines are systematicallydeveloped statements to assist in themaking of practitioner and patientdecisions regarding appropriatehealth care for specific clinicalcircumstances Practice guidelinesshould be based on scientificevidence of effectiveness orpredictability They counter thetendency for medical practice to beanecdotal and parochial by forcinghealth professionals to examineknowledge and practice patterns Bysystematically influencing clinicaldecisions practice guidelines candecrease unnecessary variations incare and improve quality52 Well-developed practice guidelinescrystallize research and makeinformation available in a usableformat5354 When there is not clearevidence to support 1 managementstrategy guidelines can be written asacceptable alternative treatmentoptions rather than as standardizedpractices that dictate specifictreatments Physicians need not berequired to use the practical toolsoffered but must be held accountableto the quality and safety of patientcare standards Often guidelines aretranslated into clinical pathways TheCochrane group defines a clinicalpathway as containing 5 keyelements55 as follows

bull a structured multidisciplinary planof care

bull translation of guidelines or evi-dence into local structure

bull detailed management steps

bull time- or criteria-based progressionand

PEDIATRICS Volume 135 number 1 January 2015 e275 by guest on March 15 2020wwwaappublicationsorgnewsDownloaded from

bull aims to standardize care for a spe-cific problem in a specificpopulation

Use of Guidelines

The use of guidelines and clinicalpathways has clearly improvedquality of care Examples of publishedguidelines that have been shown toimprove outcomes in pediatricemergency care include those forbronchiolitis croup asthma imagingfor appendicitis and management ofpatients with acute exacerbations ofinborn errors of metabolism4056ndash58

However even when guidelines existthere is inconsistent application byproviders as noted in a study onmanaging fever in young childrenThe authors concluded that thevariation in the use of the guidelinesbetween emergency physiciansaffected both cost and quality ofcare59 It is important for guidelinesto be presented as a tool used inconjunction with clinical judgmentand not as a substitute for theproviderrsquos ability to treat each childas an individual Physician ldquobuy inrdquo isone of the most significant barriers toimplementing guidelines6061 Theconcept that guidelines limit thephysician to think freely or mandatea specific intervention may limitphysiciansrsquo acceptance of a guidelinePhysician input early in thedevelopment of a guideline may assistacceptance from the practicingcommunity Guidelines strongly basedon evidence are more likely to beused as well Additionally real-timereminders and effective leaders aremore successful than passiveeducation in aiding guidelineutilization62

Implementation at the local levelmust incorporate issues related to theculture ethnicity and socioeconomicsof the particular community Whenfeasible all levels of providers whoparticipate in the emergency care ofchildren should be involved in thedevelopment of guidelines to ensurethat the many factors influencing the

pediatric care outcomes areconsidered63 Advanced-practicenurses physician assistants nurseshealth plan representatives injuryprevention professionals and socialservices providers also shouldcollaborate in guideline development

STRATEGIES FOR IMPROVING EDPATIENT FLOW

ED flow the roadmap for addressingefficiencies is a combination of triageefficiency of evaluation resourceutilization patient length of stay inthe ED and inpatient bedavailability2963ndash65 Publishedaccounts of successfully improvingED throughput measures usually usea combination of the strategiesdiscussed below66

LEAN methodology

LEAN a set of business operatingprinciples developed by Japaneseauto manufacturers operates on a setof core principles that included thefollowing evaluation of systemsidentification of waste elimination ofwaste improvement of flow andconstant adaption andimprovement67 A critical aspect ofthe LEAN system is to involve thoseproviding value-added steps in everylevel of process design andmodification or a ldquobottom uprdquomanagement68 This methodology hasbeen shown to be effective inimproving ED process efficiencies ina study working specifically in thearea of Rapid Triage and Treatment ofan ED with both adult and pediatricpatients69

Emergency Care Pathways

Emergency care pathways and theuse of clinical practice guidelines intriage in particular have been shownto decrease length of stay improveresource utilization and facilitateefficient throughput70ndash72 There aremany more published examples of theeffect of adult triage or general triagepathways versus pediatric-specifictriage pathways However some

pediatric-specific pathways have beenshown to have an effect on ED patientflow73ndash75

Developing emergency care pathwaysthat adequately address pediatricissues and prioritize problems inaccordance with those of adults isa priority An increasing number andquality of pediatric-specific triagepathways are available the mostnotable being the 5-level triagesystem76ndash80 If there are inadequatetriage categorizations orreevaluations then children may notbe receiving appropriateprioritization for care Additionallyparents who have been waiting forvery long periods of time may leavebefore treatment is complete becausethe wait time is too long81

Innovative Staffing Models

Optimizing resources is one of the toppriorities in improving crowding inthe ED Although the research oninnovative staffing models is stillevolving the existing evidenceindicates that utilizing nursepractitioners or physician assistantsas part of the overall ED health careteam can have positive effects on bothpatient flow8283 and patientsatisfaction84ndash86

Although a certain percentage ofpediatric patients are acutely ill orinjured many patients are of loweracuity and arrive during predictablepeak periods most notably duringevening and weekend hours The useof nurse practitioners and physicianassistants in lower-acuity settingsduring peak hours for example hasbeen found to be particularly effectiveat alleviating the stress that higher-volume lower-acuity patients have onthe system8788 Utilizing the conceptof fast track or urgent care duringthese time periods has been shown toincrease patient satisfaction for adultpatients2889

Utilizing nurse practitioners orphysician assistants (at triage ortreatment area) to assess andortreat patients also frees up the time of


emergency physicians for the morecomplex cases90 It can createa bottleneck in triage however ifa patient with a seemingly minorissue turns out to be morecomplicated thus requiring moretime in the evaluation phase Thismodel requires flexibility in bothscheduling and backup91ndash93

Alternatively physician-led teamtriage models have also beenassociated with improved throughputand quality of care In 1 study anemergency physicianndashled team triagemodel was compared with thetraditional model of nurse firstphysician second This model used inadult and pediatric patients wasassociated with decreased length ofstay in the ED decreased rate ofpatients who left without treatmentdecreased rate of patients whoreturned for an unscheduled visitand decreased mortality within7 days94 Rogg et al95 using a similarmodel found a sustainedimprovement (over 3 years) in lengthof stay for all of their ED patientswhether they were actually seen bythe physician-led triage team Theyalso saw a sustained improvement inthe rate of patients leaving withoutbeing seen Others have shown moremodest benefits in throughputmeasures when using similarmodels9697 The increasing demandfor ED care is expected to continueand EDs will need to continue toadapt to meet the changingexpectations of the populations theyserve90

The Impact of Value-BasedReimbursement

Tightening health budgets and theintroduction of value-basedreimbursement have contributed toan increased focus on improvingpatient flow and patient satisfactionwithout compromising quality of careIn the ED environment lower-acuitypatients typically wait the longest tobe seen by a physician Wait times areknown to be a key factor in patientsatisfaction and studies have shown

that patient satisfaction scores areoften lowest among the lower-acuitypatients84 The low-acuityenvironment has therefore becomea focus for innovative care solutionsthat can reduce wait times for allpatients not just those with minorpresentations98

A systematic search of the Englishand French literature included66 papers on the use of physicianassistants in EDs and studied severaloutcomes including changes inpatient flow and patient satisfactionduring the period of physicianassistant utilization The paperswhich discussed the effects on patientlength of stay during the period ofphysician assistant utilizationreported that length of stay wasreduced when physician assistantswere introduced although the shorttime period of 1 study limited itsgeneralizability One of these studieswas in a US hospital thatimplemented a fast-track unit staffedby physician assistants and alsofound that patient satisfaction wassignificantly higher after itsintroduction83

Traditionally patient registration hasoccurred before or during triageAlthough accurate identification ofpatients is essential for provision ofsafe and quality emergency carecompletion of patient registrationafter triage in the examination roomand the use of bar-coded patientidentification bands have both beenshown to improve patient throughputtimes while maintaining patientsafety99100

Staffing Patterns and ldquoFastTrackingrdquo

Seasonal variation with peaks in thewinter months for influenza andrespiratory illnesses and in thesummer months for trauma withfractures and lacerations is alsopredictable ED management canoptimize supply and demand byproactively planning for these peakperiods with increased staffing and

surge space allowances101102

Computer modeling of patient flowhas been used successfully to predictthe effects of physician staffingpatterns on patient throughput ina pediatric ED103

ED to Observation Units or InpatientTransition

Observation units are another optionfor relieving high-volume stress ina crowded ED Observation units havebeen shown to reduce ED crowdingby decreasing inpatient admissionsand length of ED stay improvingefficiency and increasing rates ofpatient and staff satisfaction Thetypes of patients best served in theseunits include those with asthmacroup gastroenteritis dehydrationabdominal pain andpoisoning104ndash108 If the ED space andstaffing are insufficient to adequatelyjustify either an urgent care orobservation service another modelcan be used A hybrid unit can besuccessfully created by sharing orcombining resources with generalpediatric inpatient or other pediatricoutpatient services109110

The inability to transfer patients toinpatient beds quickly has beenshown to be one of the mostimportant factors influencing EDefficiency of flow in studies of adultand general EDs111112 There arefewer data on the effects of inpatientoccupancy on throughput in pediatricEDs However 1 study at an urbanchildrenrsquos hospital showed anassociation between inpatientoccupancy rate and ED crowdingmeasures High hospital occupancydirectly correlated with longer lengthof stay for all patients treated in theED When inpatient occupancy was ator more than 80 of capacity every5 increase in hospital occupancywas associated with an increase inlength of stay of 177 minutes forpatients who were discharged(95 CI 22ndash332 minutes) and343 minutes for patients who wereadmitted (95 CI 114ndash572minutes) With the same 5 increase


in inpatient occupancy there wereincreases in the odds of eithera patient leaving without being seen(OR 121 95 CI 112ndash131) orbeing treated in a hallway bed(OR 118 95 CI 115ndash122)113

The development of an early alertsystem for housewide awareness ofreduced bed availability is key toensuring that all stakeholders canimmediately be made aware wheninpatient beds become scarce or areno longer available This alert systemcan be tiered to the point at whichthere are no inpatient beds the ED isfull and transfers can no longer beaccepted For this alert system to bemost effective it should include notonly the admitting office or high-levelnursing administrators but alsocharge nurses on all floors operatingrooms same-day surgery recoveryroom and the ED all inpatientphysicians and residents who may bethe providers responsible for actuallywriting the discharge orders114

In many hospitals the ED accountsfor the majority of admissionsAnother avenue to help ED crowdingis for hospitals to review andstreamline processes for admission tothe hospital including the balance ofED space utilization for adequate flowto keep patients from leaving becausethere are no ED beds to be able to seethe patients Accurate patientplacement at all levels will helpimprove ED overcrowding

Hospital administration may examineall aspects of admission anddischarge processes to streamline anddecrease the time and resourcesrequired Daily safety updatesfacilitated by hospital administrationprovide a venue whereby all keyhospital areas give a brief updateabout the unit staffing and potentialissues and are a quality and safetyconcept that have been working inmany institutions in the OhioChildrenrsquos Hospital Solutions forPatient Safety network115 Combiningdaily safety updates with availableelectronic dashboards to show

patient flow in the ED and inpatientunits can help managers predict real-time unit needs More intense effortsmust be focused toward earlierinpatient discharges Some have evensuggested positive incentives forearlier rounding and discharges withcorresponding negative consequencesfor failure to comply Play areas andchild lifendashfacilitated family or groupwaiting rooms can be highlyadvantageous for patients waiting forparents or rides as they free upa room to be cleaned and turned overto another patient

Finally ED managers may proactivelyconsider the optimal use of returnvisits to the ED versus referral tourgent care and other outpatientsites This ED return visit systemincludes a detailed list of availabilityand hours of service that address theaccess and service needs of thepatients community and hospitalsystem and requires coordinationwith the hospital outpatient clinicsand community physicians to ensureefficient use of resources

PERFORMANCE MEASUREDEVELOPMENT

Performance measures can be used toprovide continuous measurement ofhealth care delivery within thesystem identify areas of excellenceprovide a mechanism for earlyawareness of a potential problemverify effectiveness of a correctiveaction and compare performancewith that of peers Measures can becategorized as structural process oroutcome indicators Structuralelements provide indirect quality-of-care measures related to a physicalsetting and resources Processindicators provide a measure ofquality of care and services byevaluating the method or process bywhich care is delivered includingboth technical and interpersonalcomponents Outcome elementsdescribe valued results related tolengthening life relieving painreducing disabilities and satisfying

the consumer An alternate methodfor classifying performance measuresutilizes 4 categories includingcondition-specific measures such asthose for otitis media childhoodasthma and infectious diseasesmeasures of consumer satisfactionsuch as satisfaction with theemergency medical techniciansnurses or physicians generalmeasures of health status such aslimitations in social activitiesphysical activities and general mentalhealth and system measures ofaccess and use of services such asrate of referrals to pediatricspecialists and disenrollmentThese classification structures forquality review are not mutuallyexclusive and bring valuableperspectives to the concept ofperformance measures

Previous work has recommendedseveral paradigms for determiningperformance measures Outcomesused for emergency medicineperformance measurement haveincluded mortality and morbidity EDlength of stay inappropriateadmissions unplanned return EDvisits unplanned primary care visitsuse of diagnostic tests and imagingequipment and use of ED personnelUsing this concept a Canadian expertconsensus panel met to (1) definea set of common conditions andoutcomes by age group to assesspediatric ED care (2) identify linksbetween processes of care andoutcomes for each of theseconditions (3) define an explicit setof process and outcome indicators forthese conditions and (4) determinethe extent to which it is possible tomeasure these indicators by using anexisting population-basedadministrative data set Theconditions identified are common aretreated in most EDs encompassa range of patient acuity and haveevidence for best practices toimprove outcomes or enhance clinicalefficiency Notably however the paneldid not explicitly rate the level ofevidence for each clinical condition49


The American College of CardiologyAmerican Heart Associationguidelines for the identification ofperformance indicators likely toimprove quality recommendconsideration of the following(1) the strength of evidencesupporting the measure (2) theclinical relevance of the outcomesassociated with the performancemeasure and (3) the magnitude ofthe relationship between theperformance measure and outcomeThe guidelines also emphasizea fourth consideration the expenseof implementing performancemeasurement when selectinga measure with the greatestlikelihood of providing meaningfulbenefit Quality improvementprograms identify performancemeasures and related interventionsthat are cost-effective116

SUMMARY

In summary ED care and flow can beimproved by implementing bestpractices at several steps in theworkflow Several points of impactcan reduce ED boarding improvepediatric patient safety and promoteeffective efficient timely and patient-centered care These points of impactinclude the 5-level triage system andnurse-initiated emergency carepathways at the point of initialassessment without delay in seeinga provider fast tracking and cohortingof patients clinical pathways andresponsive staffing as patientsadvance through the ED systemSpecific plans may be in place for anypatient boarded while awaiting carefor an emotional illness andorsubstance abuse issue30

Interdisciplinary collaborativeresearch and education are needed todevelop and implement newsolutions and strategies to bothprevent and manage ED crowding117

All health care providers involved inthe delivery of pediatric emergencycare are actively engaged in definingwhat pediatric quality care is andhow to translate best practices into

guidelines that are easilydisseminated and simple to follow

LEAD AUTHORS

Isabel A Barata MD FACEPKathleen M Brown MD FACEPLaura Fitzmaurice MD FACEP FAAPElizabeth Stone Griffin RNSally K Snow BSN RN

AMERICAN ACADEMY OF PEDIATRICS (AAP)COMMITTEE ON PEDIATRIC EMERGENCYMEDICINE 2013ndash2014

Joan E Shook MD MBA FAAP ChairpersonAlice D Ackerman MD MBA FAAPThomas H Chun MD MPH FAAPGregory P Conners MD MPH MBA FAAPNanette C Dudley MD FAAPSusan M Fuchs MD FAAPMarc H Gorelick MD MSCE FAAPNatalie E Lane MD FAAPBrian R Moore MD FAAPJoseph L Wright MD MPH FAAP

LIAISONS

Lee Benjamin MD ndash American College of Emergency

Physicians

Kim Bullock MD ndash American Academy of Family

Physicians

Beth Edgerton MD MPH ndash Maternal and Child Health

Bureau

Toni Gross MD MPH FAAP ndash National Association of

EMS Physicians

Tamar Margarik Haro ndash AAP Department of Federal

Affairs

Angela Mickalide PhD MCHES ndash EMSC National

Resource Center

Elizabeth L Robbins MD FAAP ndash AAP Section on

Hospital Medicine

Lou Romig MD FAAP ndash National Association of

Emergency Medical Technicians

Sally K Snow RN BSN ndash Emergency Nurses

Association

David W Tuggle MD FAAP ndash American College of

Surgeons

Cynthia Wright MSN RNC ndash National Association of

State EMS Officials

STAFF

Sue Tellez

AMERICAN COLLEGE OF EMERGENCYPHYSICIANS PEDIATRIC EMERGENCYMEDICINE COMMITTEE 2013ndash2014

Lee S Benjamin MD FACEP ChairpersonIsabel A Barata MD FACEP FAAPKiyetta Alade MDJoseph Arms MDJahn T Avarello MD FACEPSteven Baldwin MDKathleen Brown MD FACEPRichard M Cantor MD FACEPAriel Cohen MDAnn Marie Dietrich MD FACEP

Paul J Eakin MDMarianne Gausche-Hill MD FACEP FAAPMichael Gerardi MD FACEP FAAPCharles J Graham MD FACEPDoug K Holtzman MD FACEPJeffrey Hom MD FACEPPaul Ishimine MD FACEPHasmig Jinivizian MDMadeline Joseph MD FACEPSanjay Mehta MD Med FACEPAderonke Ojo MD MBBSAudrey Z Paul MD PhDDenis R Pauze MD FACEPNadia M Pearson DOBrett Rosen MDW Scott Russell MD FACEPMohsen Saidinejad MDHarold A Sloas DOGerald R Schwartz MD FACEPOrel Swenson MDJonathan H Valente MD FACEPMuhammad Waseem MD MSPaula J Whiteman MD FACEPDale Woolridge MD PhD FACEP

FORMER COMMITTEE MEMBERS

Carrie DeMoor MDJames M Dy MDSean Fox MDRobert J Hoffman MD FACEPMark Hostetler MD FACEPDavid Markenson MD MBA FACEPAnnalise Sorrentino MD FACEPMichael Witt MD MPH FACEP

STAFF

Dan SullivanStephanie Wauson

EMERGENCY NURSES ASSOCIATIONPEDIATRIC COMMITTEE 2012ndash2013

Sally K Snow BSN RN CPEN FAEN 2011 ChairMichael Vicioso MSN RN CPEN CCRN 2012 ChairShari A Herrin MSN MBA RN CEN 2013 ChairJason T Nagle ADN RN CEN CPEN NREMT-PSue M Cadwell MSN BSN RN NE-BCRobin L Goodman MSN RN CPENMindi L Johnson MSN RNWarren D Frankenberger MSN RN CCNSAnne M Renaker DNP RN CNS CPENFlora S Tomoyasu MSN BSN RN CNS PHRN

BOARD LIAISONS

2012 ndash Deena Brecher MSN RN APRN CEN CPENACNS-BC2013 ndash Sally K Snow BSN RN CPEN FAEN

STAFF LIAISONS

Kathy Szumanski MSN RN NE-BCDale Wallerich MBA BSN RN CENMarlene Bokholdt MS RN CPENPaula Karnick PhD CPNP ANP-BCLeslie GatesChristine Siwik


REFERENCES

1 McCaig LF National Hospital AmbulatoryMedical Care Survey 1992 emergencydepartment summary Adv Data 1994(245)1ndash12

2 McCaig LF Burt CW National HospitalAmbulatory Medical Care Survey 2003emergency department summary AdvData 2005(358)1ndash37

3 Pitts SR Pines JM Handrigan MTKellermann AL National trends inemergency department occupancy 2001to 2008 effect of inpatient admissionsversus emergency department practiceintensity Ann Emerg Med 201260(6)679e3ndash686e3

4 American Academy of PediatricsCommittee on Pediatric EmergencyMedicine Policy statementovercrowding crisis in our nationrsquosemergency departments is our safetynet unraveling Pediatrics 2004114(3)878ndash888 Reaffirmed June 2011

5 Hostetler MA Mace S Brown K et alSubcommittee on EmergencyDepartment Overcrowding andChildren Section of PediatricEmergency Medicine American Collegeof Emergency Physicians Emergencydepartment overcrowding and childrenPediatr Emerg Care 200723(7)507ndash515

6 Twanmoh JR Cunningham GP Whenovercrowding paralyzes an emergencydepartment Manag Care 200615(6)54ndash59

7 McCarthy ML Zeger SL Ding R LevinSR Crowding delays treatment andlengthens emergency departmentlength of stay even among high-acuitypatients Ann Emerg Med 200954(4)492e4ndash503e4

8 Timm NL Ho ML Luria JW Pediatricemergency department overcrowdingand impact on patient flow outcomesAcad Emerg Med 200815(9)832ndash837

9 Gilboy N Tanabe T Travers D RosenauAM Emergency Severity Index (ESI) ATriage Tool for Emergency DepartmentCare Version 4 ImplementationHandbook 2012 Edition Rockville MDAgency for Healthcare Research andQuality November 2011 AHRQPublication 12-0014

10 Horwitz LI Bradley EH Percentage of USemergency department patients seenwithin the recommended triage time

1997 to 2006 Arch Intern Med 2009169(20)1857ndash1865

11 Pines JM Localio AR Hollander JE et alThe impact of emergency departmentcrowding measures on time toantibiotics for patients with community-acquired pneumonia Ann Emerg Med200750(5)510ndash516

12 Lambe S Washington DL Fink A et alWaiting times in Californiarsquos emergencydepartments Ann Emerg Med 200341(1)35ndash44

13 Sills M Fairclough D Ranade D KahnMG Emergency department crowding isassociated with decreased quality ofcare for children with acute asthmaAnn Emerg Med 201157(3)191e7ndash200e7

14 Shenoi R Ma L Syblik D Yusuf SEmergency department crowding andanalgesic delay in pediatric sickle cellpain crises Pediatr Emerg Care 201127(10)911ndash917

15 Pines JM Hollander JE Emergencydepartment crowding is associatedwith poor care for patients withsevere pain Ann Emerg Med 200851(1)1ndash5

16 Fee C Weber EJ Maak CA Bacchetti PEffect of emergency departmentcrowding on time to antibiotics inpatients admitted with community-acquired pneumonia Ann Emerg Med200750(5)501e1ndash509e1

17 Mills AM Shofer FS Chen EH HollanderJE Pines JM The association betweenemergency department crowding andanalgesia administration in acuteabdominal pain patients Acad EmergMed 200916(7)603ndash608

18 Hwang U Richardson L Livote E HarrisB Spencer N Sean Morrison REmergency department crowding anddecreased quality of pain care AcadEmerg Med 200815(12)1248ndash1255

19 Epstein SK Huckins DS Liu SW et alEmergency department crowding andrisk of preventable medical errorsIntern Emerg Med 20127(2)173ndash180

20 Kulstad EB Sikka R Sweis RT Kelley KMRzechula KH ED overcrowding isassociated with an increased frequencyof medication errors Am J Emerg Med201028(3)304ndash309

21 Sun BC Hsia RY Weiss RE et al Effect ofemergency department crowding on

outcomes of admitted patients AnnEmerg Med 201361(6)605e6ndash611e6

22 Boudreaux ED OrsquoHea EL Patientsatisfaction in the emergencydepartment a review of the literatureand implications for practice J EmergMed 200426(1)13ndash26

23 Tekwani KL Kerem Y Mistry CD et alEmergency department crowding isassociated with reduced satisfactionscores in patients discharged from theemergency department West J EmergMed 210314(1)11ndash15

24 Sun BC Adams J Orav EJ Rucker DWBrennan TA Burstin HR Determinantsof patient satisfaction and willingnessto return with emergency care AnnEmerg Med 200035(5)426ndash434

25 Pines JM Iyer S Disbot M Hollander JEShofer FS Datner EM The effect ofemergency department crowding onpatient satisfaction for admittedpatients Acad Emerg Med 200815(9)825ndash831

26 Magaret ND Clark TA Warden CRMagnusson AR Hedges JR Patientsatisfaction in the emergencydepartmentmdasha survey of pediatricpatients and their parents Acad EmergMed 20029(12)1379ndash1388

27 Rodi SW Grau MV Orsini CM Evaluationof a fast track unit alignment ofresources and demand results inimproved satisfaction and decreasedlength of stay for emergencydepartment patients Qual ManagHealth Care 200615(3)163ndash170

28 Spaite DW Bartholomeaux F Guisto Jet al Rapid process redesign ina university-based emergencydepartment decreasing waiting timeintervals and improving patientsatisfaction Ann Emerg Med 200239(2)168ndash177

29 Bernstein SL Aronsky D Duseja R et alSociety for Academic EmergencyMedicine Emergency DepartmentCrowding Task Force The effect ofemergency department crowding onclinically oriented outcomes AcadEmerg Med 200916(1)1ndash10

30 MCN Healthcare Joint Commissionrevises two standards related topatient flow through the emergencydepartment Published May 16 2012Available at wwwmcnhealthcarecomstayalertalertsa_2523Joint-


commission-Revises Accessed April 142014

31 McHugh M Van Dyke K McClelland MMoss D Improving Patient Flow andReducing Emergency DepartmentCrowding A Guide for HospitalsPrepared by the Health Research andEducational Trust an affiliate of theAmerican Hospital Association undercontract 290-200-600022 Task Order No6 Rockville MD Agency for HealthcareResearch and Quality October 2011AHRQ Publication 11(12)-0094

32 Institute of Medicine Committee on theQuality of Health Care in AmericaCrossing the Quality Chasm A NewHealth System for the 21st CenturyWashington DC National AcademiesPress 200139ndash60

33 Chassin MR Galvin RW Institute ofMedicine National Roundtable on HealthCare Quality The urgent need toimprove health care quality JAMA1998280(11)1000ndash1005

34 Corrigan JM OrsquoKane ME Assessing theQuality and Accessibility of Patient CareProvided by Health Plans WashingtonDC Physician Payment ReviewCommission 1993

35 Institute of Medicine Committee on theFuture of Emergency Care in the UnitedStates Health System Emergency Carefor Children Growing PainsWashington DC National AcademiesPress 2006

36 Centers for Medicare and MedicaidServices ldquoStanding ordersrdquo in hospitalsmdashrevisions to SampC memorandaMemorandum sent to State SurveyAgency Directors October 24 2008Available at httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertificationGenInfodownloadsSCLetter09-10pdf AccessedApril 14 2014

37 Zand DJ Brown KM Lichter-Konecki UCampbell JK Salehi V Chamberlain JMEffectiveness of a clinical pathway forthe emergency treatment of patientswith inborn errors of metabolismPediatrics 2008122(6)1191ndash1195

38 Brown K Martinez A Sun S Teach SChamberlain J Addition of a standingorder for dexamethasone to anemergency department asthmapathway is associated with improvedpatient outcomes [abstract] Presented

at Pediatric Academic Societies AnnualMeeting May 1ndash4 2010 VancouverCanada Available at httpwwwabstracts2viewcompasallviewphpnu=PAS10L1_3290 Accessed November12 2014

39 Browne GJ Giles H McCaskill MEFasher BJ Lam LT The benefits of usingclinical pathways for managing acutepaediatric illness in an emergencydepartment J Qual Clin Pract 200121(3)50ndash55

40 Scribano PV Lerer T Kennedy DCloutier MM Provider adherence toa clinical practice guideline for acuteasthma in a pediatric emergencydepartment Acad Emerg Med 20018(12)1147ndash1152

41 Goldberg R Chan L Haley P Harmata-Booth J Bass G Critical pathway for theemergency department management ofacute asthma effect on resourceutilization Ann Emerg Med 199831(5)562ndash567

42 Retezar R Bessman E Ding R Zeger SLMcCarthy ML The effect of triagediagnostic standing orders onemergency department treatment timeAnn Emerg Med 201157(2)89ndash99 e2

43 Nicholls D Gaynor N Shafiei T BosanacP Farrell G Mental health nursing inemergency departments the case fora nurse practitioner role J Clin Nurs201120(3ndash4)530ndash536

44 The Joint Commission Standardsrevisions to address patient flowthrough the emergency departmentOakbrook Terrace IL The JointCommission 2012 Available at wwwjointcommissionorgassets118Pre_Publication_EDO_HAPpdf AccessedApril 14 2014

45 Beal AC Co JP Dougherty D et alQuality measures for childrenrsquos healthcare Pediatrics 2004113(1 pt 2)199ndash209

46 Ferris TG Dougherty D Blumenthal DPerrin JM A report card on qualityimprovement for childrenrsquos health carePediatrics 2001107(1)143ndash155

47 Lindsay P Schull M Bronskill SAnderson G The development ofindicators to measure the qualityof clinical care in emergencydepartments following a modified-delphi approach Acad Emerg Med20029(11)1131ndash1139

48 Guttmann A Razzaq A Lindsay PZagorski B Anderson GM Developmentof measures of the quality ofemergency department care forchildren using a structured panelprocess Pediatrics 2006118(1)114ndash123

49 Hung GR Chalut D A consensus-established set of important indicatorsof pediatric emergency departmentperformance Pediatr Emerg Care200824(1)9ndash15

50 Khan NS Jain S Quality initiatives in theemergency department Curr OpinPediatr 201022(3)262ndash267

51 Alessandrini E Varadarajan K AlpernER et al Pediatric Emergency CareApplied Research Network Emergencydepartment quality an analysis ofexisting pediatric measures AcadEmerg Med 201118(5)519ndash526

52 Armon K MacFaul R Hemingway PWerneke U Stephenson T The impact ofpresenting problem based guidelinesfor children with medical problems inan accident and emergencydepartment Arch Dis Child 200489(2)159ndash164

53 Wright SW Trott A Lindsell CJ Smith CGibler WB Evidence-based emergencymedicine Creating a system tofacilitate translation of evidence intostandardized clinical practicea preliminary report Ann Emerg Med200851(1)80ndash86 e1ndashe8

54 Bergman DA Evidence-based guidelinesand critical pathways for qualityimprovement Pediatrics 1999103(1suppl E)225ndash232

55 Kinsman L Rotter T James E Snow PWillis J What is a clinical pathwayDevelopment of a definition to informthe debate BMC Med 2010831

56 Guttmann A Zagorski B Austin PC et alEffectiveness of emergency departmentasthma management strategies onreturn visits in children a population-based study Pediatrics 2007120(6)Available at wwwpediatricsorgcgicontentfull1206e1402

57 Chin R Browne GJ Lam LT McCaskillME Fasher B Hort J Effectiveness ofa croup clinical pathway in themanagement of children with crouppresenting to an emergencydepartment J Paediatr Child Health200238(4)382ndash387


58 Ramarajan N Krishnamoorthi R BarthR et al An interdisciplinary initiative toreduce radiation exposure evaluationof appendicitis in a pediatricemergency department with clinicalassessment supported by a stagedultrasound and computed tomographypathway Acad Emerg Med 200916(11)1258ndash1265

59 Isaacman DJ Kaminer K Veligeti HJones M Davis P Mason JDComparative practice patterns ofemergency medicine physicians andpediatric emergency medicinephysicians managing fever in youngchildren Pediatrics 2001108(2)354ndash358

60 Butterfoss FD Major DA Clarke SMet al What providers from generalemergency departments say aboutimplementing a pediatric asthmapathway Clin Pediatr (Phila) 200645(4)325ndash333

61 Olajos-Clow J Szpiro K Julien B MinardJ Lougheed MD Emergencydepartment adult asthma carepathway healthcare providersrsquoperceived utility and barriers toimplementation Adv Emerg Nurs J200931(1)44ndash53

62 Grol R Dalhuijsen J Thomas S Veld CRutten G Mokkink H Attributes ofclinical guidelines that influence use ofguidelines in general practiceobservational study BMJ 1998317(7162)858ndash861

63 Yen K Gorelick MH Strategies toimprove flow in the pediatric emergencydepartment Pediatr Emerg Care 200723(10)745ndash749 quiz 750ndash751

64 Chan L Reilly KM Salluzzo RF Variablesthat affect patient throughput times inan academic emergency departmentAm J Med Qual 199712(4)183ndash186

65 American College of EmergencyPhysicians Boarding of pediatricpatients in the emergency departmentpolicy statement Ann Emerg Med 201259(5)406ndash407

66 LeBaron J Culberson MC III WileyJF II Smith SR ldquoBe quickrdquo a systemsresponse to overcrowding in thepediatric emergency departmentPediatr Emerg Care 201026(11)808ndash813

67 Liker J The Toyota Way New York NYMcGraw-Hill 2004

68 Jimmerson C Weber D Sobek DK IIReducing waste and errors pilotinglean principles at IntermountainHealthcare Jt Comm J Qual Patient Saf200531(5)249ndash257

69 Murrell KL Offerman SR Kauffman MBApplying LEAN implementation ofa rapid triage and treatment systemWest J Emerg Med 201112(2)184ndash191

70 Fosnocht DE Swanson ER Use ofa triage pain protocol in the ED Am JEmerg Med 200725(7)791ndash793

71 Fan J Woolfrey K The effect of triage-applied Ottawa Ankle Rules on thelength of stay in a Canadian urgentcare department a randomizedcontrolled trial Acad Emerg Med 200613(2)153ndash157

72 Chan TC Killeen JP Kelly D Guss DAImpact of rapid entry and acceleratedcare at triage on reducing emergencydepartment patient wait times lengths ofstay and rate of left without being seenAnn Emerg Med 200546(6)491ndash497

73 Choi J Claudius I Decrease inemergency department length of stayas a result of triage pulse oximetryPediatr Emerg Care 200622(6)412ndash414

74 Abanses JC Dowd MD Simon SDSharma V Impact of rapid influenzatesting at triage on management offebrile infants and young childrenPediatr Emerg Care 200622(3)145ndash149

75 Karpas A Hennes H Walsh-Kelly CMUtilization of the Ottawa ankle rules bynurses in a pediatric emergencydepartment Acad Emerg Med 20029(2)130ndash133

76 Maldonado T Avner JR Triage of thepediatric patient in the emergencydepartment are we all in agreementPediatrics 2004114(2)356ndash360

77 Bergeron S Gouin S Bailey B Amre DKPatel H Agreement among pediatrichealth care professionals with thepediatric Canadian triage and acuityscale guidelines Pediatr Emerg Care200420(8)514ndash518

78 Mistry RD Cho CS Bilker WBBrousseau DC Alessandrini EACategorizing urgency of infantemergency department visitsagreement between criteria AcadEmerg Med 200613(12)1304ndash1311

79 Baumann MR Strout TD Evaluation ofthe Emergency Severity Index (version

3) triage algorithm in pediatricpatients Acad Emerg Med 200512(3)219ndash224

80 Gravel J Gouin S Bailey B Roy MBergeron S Amre D Reliability ofa computerized version of the PediatricCanadian Triage and Acuity Scale AcadEmerg Med 200714(10)864ndash869

81 Rapid ED access reduces patientsleaving without being seen PerformImprov Advis 20059(10)114ndash115 109

82 Nestler DM Fratzke AR Church CJ et alEffect of a physician assistant as triageliaison provider on patient throughputin an academic emergency departmentAcad Emerg Med 201219(11)1235ndash1241

83 Doan Q Sabhaney V Kissoon N Sheps SSinger J A systematic review the roleand impact of the physician assistant inthe emergency department Emerg MedAustralas 201123(1)7ndash15

84 Jeanmonod R Delcollo J Jeanmonod DDombchewsky O Reiter M Comparisonof resident and mid-level providerproductivity and patient satisfaction inan emergency department fast trackEmerg Med J 201330(1)e12

85 Hooker RS Klocko DJ Larkin GLPhysician assistants in emergencymedicine the impact of their role AcadEmerg Med 201118(1)72ndash77

86 Hoskins R Evaluating new roles withinemergency care a literature review IntEmerg Nurs 201119(3)125ndash140

87 Carter AJ Chochinov AH A systematicreview of the impact of nursepractitioners on cost quality of caresatisfaction and wait times in theemergency department CJEM 20079(4)286ndash295

88 Ganapathy S Zwemer FL Jr Coping witha crowded ED an expanded unique rolefor midlevel providers Am J EmergMed 200321(2)125ndash128

89 Sanchez M Smally AJ Grant RJ JacobsLM Effects of a fast-track area onemergency department performanceJ Emerg Med 200631(1)117ndash120

90 Callander EJ Schofield DJ Emergencydepartment workforce models whatthe literature can tell us Emerg MedAustralas 201123(1)84ndash94

91 Simon LV Matteucci MJ Tanen DA RoosJA Riffenburgh RH The Pittsburgh


Decision Rule triage nurse versusphysician utilization in the emergencydepartment J Emerg Med 200631(3)247ndash250

92 Doctor in triage slices door-to-discharge times ED Manag 200618(5)54ndash55

93 lsquoPITrsquo more than triples EDrsquos satisfactionrates ED Manag 200719(9)101ndash102

94 Burstroumlm L Nordberg M Ornung Get al Physician-led team triage basedon lean principles may be superior forefficiency and quality A comparisonof three emergency departments withdifferent triage models Scand JTrauma Resusc Emerg Med 20122057

95 Rogg JG White BA Biddinger PD ChangY Brown DF A long-term analysis ofphysician triage screening in theemergency department Acad EmergMed 201320(4)374ndash380

96 Han JH France DJ Levin SR Jones IDStorrow AB Aronsky D The effect ofphysician triage on emergencydepartment length of stay J EmergMed 201039(2)227ndash233

97 Cheng I Lee J Mittmann N et alImplementing wait-time reductionsunder Ontario government benchmarks(Pay-for-Results) a cluster randomizedtrial of the effect of a physician-nursesupplementary triage assistance team(MDRNSTAT) on emergency departmentpatient wait times BMC Emerg Med20131317

98 Davidson J Rogers T A lesson from theUK Australas Emerg Nurs J 20058(1-2)5ndash8

99 Gorelick MH Yen K Yun HJ The effect ofin-room registration on emergencydepartment length of stay Ann EmergMed 200545(2)128ndash133

100 Bar-coded patient IDs cut LOS nearlyone hour ED Manag 200416(12)139ndash140

101 Fagbuyi DB Brown KM Mathison DJet al A rapid medical screeningprocess improves emergencydepartment patient flow during surge

associated with novel H1N1 influenzavirus Ann Emerg Med 201157(1)52ndash59

102 Cooke MW Wilson S Pearson S Theeffect of a separate stream for minorinjuries on accident and emergencydepartment waiting times Emerg MedJ 200219(1)28ndash30

103 Hung GR Whitehouse SR OrsquoNeill C GrayAP Kissoon N Computer modeling ofpatient flow in a pediatric emergencydepartment using discrete eventsimulation Pediatr Emerg Care 200723(1)5ndash10

104 Silvestri A McDaniel-Yakscoe N OrsquoNeillK et al Observation medicine theexpanded role of the nurse practitionerin a pediatric emergency departmentextended care unit Pediatr Emerg Care200521(3)199ndash202

105 Mace SE Pediatric observationmedicine Emerg Med Clin North Am200119(1)239ndash254

106 Scribano PV Wiley JF II Platt K Use ofan observation unit by a pediatricemergency department for commonpediatric illnesses Pediatr Emerg Care200117(5)321ndash323

107 Hostetler B Leikin JB Timmons JAHanashiro PK Kissane K Patterns ofuse of an emergency department-basedobservation unit Am J Ther 20029(6)499ndash502

108 Conners GP Melzer SM Betts JM et alCommittee on Hospital Care Committeeon Pediatric Emergency MedicinePediatric observation units Pediatrics2012130(1)172ndash179

109 Zebrack M Kadish H Nelson D Thepediatric hybrid observation unit ananalysis of 6477 consecutive patientencounters Pediatrics 2005115(5)Available at wwwpediatricsorgcgicontentfull1155e535

110 Crocetti MT Barone MA Amin DDWalker AR Pediatric observation statusbeds on an inpatient unit an integratedcare model Pediatr Emerg Care 200420(1)17ndash21

111 Espinosa G Miroacute O Saacutenchez M Coll-Vinent B Millaacute J Effects of external and

internal factors on emergencydepartment overcrowding Ann EmergMed 200239(6)693ndash695

112 Forster AJ Stiell I Wells G Lee AJ vanWalraven C The effect of hospitaloccupancy on emergencydepartment length of stay and patientdisposition Acad Emerg Med 200310(2)127ndash133

113 Hillier DF Parry GJ Shannon MW StackAM The effect of hospital bedoccupancy on throughput in thepediatric emergency departmentAnn Emerg Med 200953(6)767e3-776e3

114 Asplin B Blum FC Broida RI et alAmerican College of EmergencyPhysicians Task Force Report onBoarding Emergency medicinecrowding high-impact solutions IrvingTX American College of EmergencyPhysicians April 2008 Available atwwwaceporgWorkArealinkitaspxLinkIdentifier=idampItemID=50026amplibID=50056 Accessed April 14 2014

115 Childrenrsquos Hospitalsrsquo Solutions forPatient Safety Web-based SPS networktogether saving lives amp reducing harm2013 Available at wwwsolutionsforpatientsafetyorgwp-contentuploadsSPS_2013AnnualReportpdf Accessed April14 2014

116 Bonow RO Masoudi FA Rumsfeld JSet al American College of CardiologyAmerican Heart Association Task Forceon Performance Measures ACCAHAclassification of care metricsperformance measures and qualitymetrics a report of the AmericanCollege of CardiologyAmerican HeartAssociation Task Force on PerformanceMeasures Circulation 2008118(24)2662ndash2666

117 Emergency Nurses Association HoldingCrowding and Patient Flow PositionStatement Des Plaines IL EmergencyNurses Association 2014 Available atwwwenaorgSiteCollectionDocumentsPosition20StatementsHoldingpdfAccessed November 10 2014


DOI 101542peds2014-3425 originally published online December 29 2014 2015135e273Pediatrics

Committee and Emergency Nurses Association Pediatric CommitteeMedicine American College of Emergency Physicians Pediatric Emergency Medicine

K Snow American Academy of Pediatrics Committee on Pediatric Emergency Isabel Barata Kathleen M Brown Laura Fitzmaurice Elizabeth Stone Griffin Sally

Emergency DepartmentBest Practices for Improving Flow and Care of Pediatric Patients in the

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1351e273including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1351e273BIBLThis article cites 94 articles 14 of which you can access for free at

Subspecialty Collections

subhttpwwwaappublicationsorgcgicollectionemergency_medicine_Emergency Medicineic_emergency_medicinehttpwwwaappublicationsorgcgicollectioncommittee_on_pediatrCommittee on Pediatric Emergency Medicinehttpwwwaappublicationsorgcgicollectioncurrent_policyCurrent Policyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on March 15 2020wwwaappublicationsorgnewsDownloaded from





httppediatricsaappublicationsorgcontent1351e273located on the World Wide Web at

The online version of this article along with updated information and services is

ISSN 1073-0397 60007 Copyright copy 2015 by the American Academy of Pediatrics All rights reserved Print the American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village Illinoishas been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it


treatment spaces increased evenmore rapidly at 31 per year3

The Effect of Crowding on Safety andQuality of Pediatric Emergency Careand Throughput

ED crowding threatens patient safetyincreases medical errors prolongslength of stay decreases patientsatisfaction and jeopardizes thereliability and ability of the US healthcare system to effectively care forpatients4ndash6 Specific examples of theeffects of ED crowding on quality ofED care including timeliness of careand patient safety have beenpublished

Studies have shown an associationbetween ED crowding andthroughput measures such as lengthof stay in EDs7 In a large urbanchildrenrsquos hospital ED boarding timeand ED daily census showedindependent associations withincreasing overall length of stay timeto triage time until seen by physicianand number of patient elopements(ie patients leaving without beingseen by a physician or leaving beforetreatment is initiated)8 Anotherstudy of 4 general EDs showed anassociation between measures ofcrowding and timeliness ofemergency care The delays affectedeven the patients with highest acuityDuring crowded periods (ie 90higher than the average census) theadjusted median waiting room timesof high-acuity level 2 patientsaccording to the 5-level EmergencySeverity Index were 3 to 35higher than during normal periods9

The percentage of patients in the EDwho are seen by a physician withinthe time recommended by triageclassification has been steadilydeclining and is at its lowest point inat least 10 years Of all the patienttriage levels in the ED the moreurgent patients are the least likely tobe seen within the triage target timePatients of all racialethnicbackgrounds and payer types havebeen similarly affected10 EDcrowding has also been shown to be

associated with an increase in therate of patients who leave withoutbeing seen by a provider11 Otherstudies have revealed that waitingtime to see an ED provider was longerat hospitals in poorer neighborhoods12

These studies show that ED crowdingmay be associated with deficits inboth the timeliness and equitability ofpatient care

Other domains of the quality of EDcare may also be affected by poor EDthroughput and crowding In a studyin pediatric ED patients experiencingan acute asthma exacerbationtimeliness and effectiveness qualitymeasures demonstrated an inversedose-related association withoccupancy and time to see anattending physician Patients were52 to 74 less likely to receivetimely care and were 9 to 14 lesslikely to receive effective care whenthe crowding measures were at the75th rather than at the 25thpercentile (P 05)13

Crowding was also associated withdelay in analgesic administration inpediatric patients with sickle cell paincrisis in a pediatric ED14 EDcrowding has also been associatedwith delay of and failure toadminister antibiotics for adultpatients admitted with community-acquired pneumonia1516 and withdelays in analgesic treatment inpatients presenting with acuteabdominal pain17 Other studies haveshown similar associations betweenED crowding and quality of care inadult ED patients including thetreatment of patients with pain1518

ED crowding is also associated withdeficits in patient safety A studyconducted in 4 general-populationEDs showed an association betweenED crowding and preventable medicalerrors19 Other investigators havealso found an association betweenED crowding measures in an adultand pediatric ED population andmedication errors20 More recentlySun et al21 demonstrated anassociation between ED crowding and

mortality hospital length of stay andcosts in 187 California hospitals Theestimate of the costs attributable toED crowding was 300 additionalinpatient deaths 6200 excess hospitaldays and $17 million in adult EDadmissions ED crowding andincreased wait times are associatedwith decreased patient satisfactionwith ED care2223 One studycompleted in 5 general teachinghospital EDs revealed that not feelinginformed about prolonged waits inadult patients was associated withgreater dissatisfaction (odds ratio[OR] 048 95 CI 039ndash057)24

Another study revealed that ED waittimes correlated with patientsrsquosatisfaction with both their ED andinpatient care25 A study in pediatricED patients showed that both parentand child satisfaction was correlatedwith wait time This study also foundthat timely resolution of pain wasimportant to both parents andchildren26 There is also evidencefrom studies in both adults andchildren that improvement in ED waittimes leads to improved patientsatisfaction2728

In summary ED crowding isa growing problem and is associatedwith increased lengths of stay in theED increased patient elopementrates and significant deficits in thequality of care domains of safety andtimeliness29 ED crowding has alsobeen linked to deficits in patientsatisfaction and the quality domainsof efficiency and equitabilityImproving ED throughput andrelieving ED crowding is an essentialcomponent of improving the qualityof ED care

Calls to Improve ED Crowding andDelivery of Care

Regulators and payers have begun torecognize and address this problemThe Joint Commission views patientflow in the ED as a patient safetyissue specifically targeting patientboarding of psychiatric patients30 In2014 the Centers for Medicare andMedicaid Services began requiring
















Use of Guidelines







LEAN methodology






































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES





































































































































































Use of Guidelines







LEAN methodology






































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES
























































































































































Use of Guidelines







LEAN methodology






































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES


















































































































































































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES



































































































































































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES
























































































































































SUMMARY





LEAD AUTHORS




LIAISONS


Physicians


Physicians


Bureau


EMS Physicians


Affairs


Resource Center


Hospital Medicine




Association


Surgeons


State EMS Officials

STAFF

Sue Tellez






STAFF




BOARD LIAISONS


STAFF LIAISONS



REFERENCES























































































































































REFERENCES

















































































































































































































































































































































































































































