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Protecting Pediatric Safety: Decreasing Potential Errors in
ED Admissions Process for Children
Susan G. Engleman, MSN, RN, APRN-BC, PNPClinical Director, Children’s System Services
Six Sigma Black BeltChildren’s Memorial Hermann Hospital
Houston, Texas
Greetings from Houston, Texas
Acknowledgements
Alicia Boaze, RN, BSN Director of Pediatrics, MHBH
Carl Hubbell, MD Pediatric Medical Director, MHBH
Michael Toomey, MBA Master Black Belt, GE Healthcare
The Impetus for Change
Practicing in clinical pediatric settings for 20 plus years and as a legal nurse consultant for 16 years, I realized several things: Healthcare professionals who do not regularly deal with
pediatrics are not as comfortable caring for children Issues frequently arise regarding pediatric patients
within a community emergency department – sometimes impacting quality and safety
Sending every child to a children’s hospital is not a viable solution to improving pediatric healthcare
Improving pediatric safety in a community ED would require a change in how these issues were addressed
Why were there no Admissions to Pediatrics on the Weekend?The pediatric unit was full during the week
when the pediatricians readily sent patients directly to the unit from their offices
However, when their offices were closed on the weekend, the unit emptied out
When questioned, the pediatricians said they felt uncomfortable with the care given to children in the emergency department
Issues Listed by the Pediatricians
No blood cultures prior to antibiotic startBagging infants for urine culturesOrders for boluses using fluids containing
glucoseOrders for fluid boluses not based upon
weight (far too much)Orders for inappropriate antibioticsInappropriate doses of antibiotics
Bottom Line MHBH, a 250-bed community hospital, in the
Memorial Hermann (MH) system moved into a new hospital in 2003. The pediatric unit added beds to total 17 beds with 3 intermediate beds in April, 2004
The staff cross-trained in the pediatric intensive care at the MH system’s trauma center
The staff attended a series of didactic courses on advanced pediatric assessment
These interventions focused heavily on improving the care for pediatric patients in the inpatient setting; however, 28% of the care for children began in the ED
Protecting Pediatric Safety:Project & Team Charter
Problem Statement: Local pediatricians are unhappy with care provided to their pediatric patients by the MHBH emergency department. This has led them to send these children to the competitor’s emergency department, especially on the weekends.
Project ScopeAll pediatric patients seen in the emergency department 24 hours per day 7 days per week.
Project GoalBy 2nd quarter FY 07 identified variances involving pediatric patients in the emergency department will be decreased by 75%.
Project Business Case: If the pediatricians are pleased with the care provided to children in the ED, they will refer their patients to MHBH increasing both ED and the pediatric unit’s volumes.
Customer(s): Primary: Local PediatriciansSecondary: Patients/FamiliesHigh Level Needs:
Safe pediatric care for children in the MHBH emergency department
Project Alignment with Strategic PlanQualityGrowthCustomer Service
Define
Project Details
What is the metric (or quality metric) that the project is trying to improve?
The metric is the count of events in the ED where the care provided or ordered by the ED physician differs or is in conflict with what the patient’s pediatrician would have found acceptable for their patient.
Possible barriers to success?
Pediatricians unable to agree to standardized process for pediatric patientsTools and processes developed not used by ED staff/physicians
Define
Current Process Map
From ED Triage to Admission or Discharge
Take Away: Our hypothesis was the variances in care would most likely occur here…
Define
Patient presents To triage
Patient triaged
Patient placed In room
Assessed By RN
Assessed By ED MD
Treatment implemented
AdmitTo Pedi
Unit
DischargeTo Home
Managing Change
Threats and Opportunity Matrix
Long term Long term
Short term
THREATS ( if we do nothing) OPPORTUNITY ( if we do this project)
• Increase in pedi volume• Happy pts, staff and
physiciansShort term
• Good P.R. • Take over pedi market in Beaumont
• Child could be harmed
• No repeat pts.• Bad P.R. • Inability to
grow service line
• Child could be harmed
• Increased complaints
• Unhappy pedi MDs• Lawsuit
Define
Define
Takeaway: The ED physicians will be the keyInfluencers of the success of this project
Managing Change
Stakeholder Analysis
Quantifying the Problem
All incident reports for 2005 in the ED involving patients aged 17 years or less were reviewed (n =18)
Eleven incident reports were related to ED patient care: antibiotic dosing, intravenous fluid choices, IV fluid dosing, missing diagnostics and accuracy of nurse to nurse reports
From these a tentative list of defects was developed. The Medical Director of Pediatrics and the Pediatric Nursing Director reviewed the list and made some additions
Measure
Revised Defect List
Inappropriate medication
Inappropriate medication dosing
Inappropriate fluid type Inappropriate fluid
amount Missing diagnostic Missing orders
Inappropriate treatment
Inappropriate triage Failure to assess or
reassess Failure to follow-up Inaccurate report Other defect
Measure
How will we sample?
8963 patients exhibited 3221 distinct diagnoses
Diagnoses were coded on a scale of 1-9 as to the likelihood that the child with that diagnosis would exhibit a defect on the list (1 = least likely; 9 = most likely)
The sample was narrowed to those children who had diagnoses coded as 7 or above (n = 1969)
22%
78%
22%
Measure
All Pediatric Patients seen in ED for 2005
Total N = 8963
Those records most likely to contain defects
N = 1969
The Rule is “Follow the Data”…
A randomized sample of 60 records was reviewed
Only 2 of the defects on the list were seen in the sample. I began to think the problem might be perception…
However, in the last two weeks, two more incident reports had been documented. Maybe not perception…
Measure
Take Away: We were not looking in the right place
Back to the Data…
Upon closer examination of the initially reviewed incident reports, it was noted that each incident occurred in a patient admitted to the Pediatric Unit and the majority had occurred in children 6 years or less
The sample of patients with diagnoses coded 7or above was then stratified further to include only children admitted to Pediatrics and 6 years or less in age (n = 222)
Measure
Findings
Six of the defects on the variance list were not found at all
Analyze
29%
17%
27%
10%
14%
3%
Inappropriate medication
Inappropriate Fluid amount
Other 3%
Inappropriate medication dosing
Inappropriate Fluid Choice
Missing Diagnostic
77 Total Defects
Take Away: The Big Ah Ha!!! Defects were found in the orders written to admit the child as an inpatient: Not in
the care delivered in the ED!!
Process CapabilityDiscrete Y
Measure
What is the Y? The count of events in the ED where the care provided or ordered by the ED physician differs or is in conflict with what the patient’s pediatrician would have found acceptable for their patient.
What is a:Defect = a potentially unsafe orderUnit = each patientOpportunity = # of potentially unsafe orders that could have been written
What is our process capability?Z score = 2.9DPMO = 80,800Yield % = 92.6% or 7 of 100 pts had defects
What is the goal? The goal is to reduce the number of events by 75% by the end of fiscal year 2nd quarter.
Patient Presents to Triage
Patient Triaged
PatientAdmitted
ED MD Writes
PediatricAdmission
Orders
Patient Reassessed by ED MD
Patient PlacedIn EDRoom
AssessedBy RN
AssessedBy
ED MDTreatment
Prescribed & Implemented
MD Decision: Discharge, Transfer or Admit
Admit To
PediatricUnit Discharge
To Home
Transfer to Higher Level
of Pediatric Care
ED MD Discusses Plan of Care
w/ Pediatrician
What the Process Map Really Looks Like….
Found the issue is
really here
Analyze
Initially thought the issue was
here
Garnering the Support of the ED MDs Findings were presented to the ED Physician group and
initial reactions were less than positive Upon realizing that the issues occurred in the admission
orders, they were less resistant, agreeing that of course this was the case; they were not “inpatient physicians”
The ED MD group recommended: Development of pre-printed pediatric admission
orders by the pediatricians for use by the ED physicians
Education for all Emergency Department nurses on the principles of caring for children
Improve
Garnering the Support of the Pediatricians Based upon the solutions generated by the ED
MDs, a meeting was planned to develop the standardized orders. Pediatricians were targeted to participate, receiving a written invitation from the director telling him that he had been “chosen to participate” in this process
This would have challenges due to the politics and number of practices in the area
The pediatric medical director assisted in the planning of the meeting since he was aware of all the “behind the scenes” information and politics
Improve
Success
Consensus reached in less than one hour
Other pediatricians invited to provide input
ED MDs accepted final order set
Pilot of 3 weeks yielded 1 defect in 20 charts
Improve
MEMORIAL HERMANN BAPTIST
BEAUMONT HOSPITAL
P. O. Box 1591 Beaumont, Texas 77704-1591
(409) 212-5000
ROUTINE ORDERS:
PEDIATRIC ADMISSION
ORDER EMERGENCY DEPARTMENT
DATE HOUR PHYSICIAN’S ORDER PAGE 1 of 1 HISTORY & PHYSICAL YES
NO
Place in Observation Status or Admit to Pediatrics
Physician: __________________________________________
Admitting Diagnosis: _________________________________
Condition: _______________
Allergies: __________________________________ Ht: _________ Wt: _________
Vital Signs: _____ Q 4 hour _____ Q 2 hours ____ Q 1 hours
Continuous Pulse Ox
Neuro Vital Signs per protocol Isolation Precautions: _________________________________
Diet: ____ Regular for age _____ NPO _____ Formula/Baby food as at home
____ Advance as tolerated _____ Clear Liquid _____ B.R.A.T. Respiratory: Nasal Canula ______LPM Cool Mist Tent RA or 30% (croup tent) Humidified Tent RA or 30% Simple Face Mask _______ LPM (> 5 lpm) 100% Non-rebreather (> 10 lpm) Albuterol (1.25 mg) / Xopenex (0.31 mg) ½ unit dose every _____ hours _______ nebulized via mask Albuterol (2.5 mg) / Xopenex (0.63 mg) unit dose every _____ hours _______ nebulized via mask Atrovent (250 mcg) ½ unit dose every _____ hours _______ nebulized via mask Atrovent (500 mcg) unit dose every _____ hours _______ nebulized via mask Labs in AM: _____ BMP _____ CBC Radiology: _____ Chest X-Ray
50%
37%
13%
Results Measured the percentage of
charts using the standardized order sets and the number of defects from the initial defect list
75 charts reviewed from a three month period
8 defects found in 525 opportunities
Order sets were used on 97% of charts
Control
Inappropriate Fluid amount
Other: Missing orders
Inappropriate medication dosing
8 Total Defects
Current defect rate = 1.5%Previous defect rate = 7.4%
Difference is statistically significant
Benefits Noted Pediatricians have verbalized satisfaction with
the order sets Pediatric Director reports no complaints about
ED from pedi MDs for the past 2 months The ED MDs happy not having to figure out what
the Pedi MDs expect for their patients Word about the quality enhancement in
Pediatrics has spread and a very busy pediatric practice is currently planning a move to the MHBH professional building. The pediatricians plan to admit to MHBH Pediatric unit
Control
Control Plan
Quarterly monitoring of the usage of the order sets and the number of defects
In September another intensive measurement of the defect rate (75 charts) will occur. If defect rate is in control, quarterly random sampling will occur
Defect rate will be measured by the process owner (Pediatric Director)
Should new defects become apparent, these will be addressed internally through a collaborative effort between the ED and pediatric medical directors
Control
Control Plan
Monitoring of order set usage will be completed by the PI RN from ED monthly
Results will be reported on the ED dashboard at the monthly ED MD meeting
Should usage “fall off”, it will be addressed in this forum by the Medical Director
Control
Conclusions and Translation
During the Improve phase of this project I was asked to take a job as Clinical Director for Children’s Service across our system
I presented the Analyze Report Out to Our Children’s Coordinating Council which is attended by all our pediatric and neonatal directors
I currently have requests to translate this project through all 8 of our other community hospitals
