10 - Improving the Safety of Pediatric Emergency Department to Inpatient Transfers of Care through Risk Stratification, Electronic Heath Record Visualization, and Interdisciplinary Reassessment Workflows

Poster Number: 10
Publication Number: 10.3287

Background: Emergency department (ED) boarding and care transitions are interconnected threats to patient safety. Boarding is associated with adverse events, nosocomial infections, extended lengths of stay, readmissions, and mortality. Transitions of care are a leading factor in adverse events. During the pediatric respiratory surge beginning September 2022, we observed a concurrent increase in boarding time associated with increased volumes, ICU upgrades, and Pediatric Response Team (PRT) activations. Review of patients’ records identified escalation to advanced respiratory modalities prior to ED departure in 30% of pediatric patients on non-invasive oxygen therapy.

Objective: To improve the structure and process of pediatric transfers of care, with a focus on patients at high-risk for care escalation.

Design/Methods: This is a longitudinal quality improvement initiative at 3 pediatric EDs in an urban, academic network. Interventions targeted improving high-risk patient detection and ensuring a complete patient reassessment prior to ED departure. A high-risk track-board (HRTB) flag, integrated within the electronic health record (EHR) ED track-board, was optimized to incorporate respiratory criteria. Workflow was structured to prompt an interdisciplinary huddle with attending reassessment prior to transport. Huddle completion was the primary process measure. Outcome measures included rates of PRTs and ICU upgrades within 6 and 24 hours from admission. Pre-(3/2022-2/2023) and post-(3/2023-9/2023) implementation rates were analyzed with Pearson's chi-squared test.

Results: Between 3/2023-9/2023, 609 patients < 18yo flagged on the HRTB (mean 2.86/day), of which 58.6% met criteria due to respiratory support. Median huddle completion was 61.4% (range, 47.5%-71.5%). PRTs within 24hr decreased post-implementation from 28.92 to 14.86 per 1,000 patients (p=0.011); PRTs within 6hr decreased from 11.87 to 6.99 per 1,000 (p=0.176). ICU upgrades similarly decreased, within 24hr from 24.54 to 16.61 per 1,000 patients (p=0.130), and those within 6 hours from 7.12 to 6.99 per 1,000 (p=0.732). While these data demonstrate concordant improvements, only PRTs within 24hr achieved statistical significance.

Conclusion(s): Integrated EHR interventions can be effectively leveraged to capture and prompt reassessments of high-risk pediatric patients, such as those requiring respiratory support. A focus on care transitions can potentially mitigate risk beyond ED care, with significant implications on hospital resources and patient safety. Future improvement cycles will focus on understanding barriers related to suboptimal process compliance.