Protecting Pediatric Safety: Decreasing Potential Errors in ED Admissions Process for Children

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Protecting Pediatric Safety Decreasing Potential
Errors in ED Admissions Process for Children

• Susan G. Engleman, MSN, RN, APRN-BC, PNP
• Clinical Director, Childrens System Services
• Six Sigma Black Belt
• Childrens Memorial Hermann Hospital
• Houston, Texas

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Greetings from Houston, Texas
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Acknowledgements

• Alicia Boaze, RN, BSN
  Director of Pediatrics, MHBH
• Carl Hubbell, MD
  Pediatric Medical Director, MHBH
• Michael Toomey, MBA
  Master Black Belt, GE Healthcare

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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 childrens 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

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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

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Issues Listed by the Pediatricians

• No blood cultures prior to antibiotic start
• Bagging infants for urine cultures
• Orders for boluses using fluids containing
  glucose
• Orders for fluid boluses not based upon weight
  (far too much)
• Orders for inappropriate antibiotics
• Inappropriate doses of antibiotics

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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 systems 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

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Protecting Pediatric SafetyProject 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
competitors emergency department, especially on
the weekends.
Project Scope All pediatric patients seen in the
emergency department 24 hours per day 7 days per
week.
Project Goal By 2nd quarter FY 07 identified
variances involving pediatric patients in the
emergency department will be decreased by
75.
Customer(s) Primary Local
Pediatricians Secondary Patients/Families High
Level Needs Safe pediatric care for children in
the MHBH emergency department
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 units
volumes.
Project Alignment with Strategic
Plan Quality Growth Customer Service
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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 patients pediatrician
would have found acceptable for their
patient.
Possible barriers to success? Pediatricians
unable to agree to standardized process for
pediatric patients Tools and processes developed
not used by ED staff/physicians
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Current Process Map
From ED Triage to Admission or Discharge
Take Away Our hypothesis was the variances in
care would most likely occur here
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Managing Change
Threats and Opportunity Matrix
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Managing Change
Stakeholder Analysis
Takeaway The ED physicians will be the
key Influencers of the success of this project
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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

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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

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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)

All Pediatric Patients seen in ED for 2005
Total N 8963
Those records most likely to contain defects N
1969
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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

Take Away We were not looking in the right place
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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)

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Findings
77 Total Defects

• Six of the defects on the variance list were not
  found at all

Inappropriate medication
Inappropriate medication dosing
Missing Diagnostic
Other 3
Inappropriate Fluid amount
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!!
Inappropriate Fluid Choice
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Process CapabilityDiscrete Y
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
patients pediatrician would have found
acceptable for their patient.
What is a Defect a potentially unsafe
order Unit each patient Opportunity of
potentially unsafe
orders that could have
been written
What is our process capability? Z score
2.9 DPMO 80,800 Yield 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.
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What the Process Map Really Looks Like.
Assessed By ED MD
Treatment Prescribed Implemented
Patient Presents to Triage
Patient Triaged
Patient Placed In ED Room
Assessed By RN
Initially thought the issue was here
Patient Reassessed by ED MD
MD Decision Discharge, Transfer or
Admit
ED MD Discusses Plan of Care w/ Pediatrician
Found the issue is really here
ED MD Writes Pediatric Admission Orders
Patient Admitted
Transfer to Higher Level of Pediatric Care
Admit To Pediatric Unit
Discharge To Home
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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

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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

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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

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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

8 Total Defects
Inappropriate medication dosing
Inappropriate Fluid amount
Other Missing orders
Current defect rate 1.5 Previous defect rate
7.4 Difference is statistically significant
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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

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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

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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

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Conclusions and Translation

• During the Improve phase of this project I was
  asked to take a job as Clinical Director for
  Childrens Service across our system
• I presented the Analyze Report Out to Our
  Childrens 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

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Questions???

• Contact Information
• Susan G. Engleman 713-704-4910
• susan.engleman_at_memorialhermann.org