Paydar-Darian N et al. Pediatr Qual Saf 2019; 4:e135.
Effecting major change while working within one small piece of a complex system is hard. This basic truth was reflected in the efforts undertaken by Dr Naloufar Paydar-Darian and her colleagues during the course of their pediatric emergency medicine fellowship in Boston. The team published their work, “Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency Department,” in February 2019, in the journal, Pediatric Quality and Safety.
Dr. Paydar-Darian sought to reduce emergency department length of stay (ED LOS) for pediatric patients requiring procedural sedation for long-bone fracture reduction. She and her team also identified that adequate communication was lacking between the multiple stakeholders involved in this complex process. She aimed to improve communication between the multiple disciplines involved in the care of these patients: emergency department physicians, orthopedic surgeons, nursing staff, and clinical assistants.
Dr. Paydar-Darian and her co-authors identified availability of ED and orthopedist team members, poor communication between members of the sedation team, patient factors (NPO times), and a poorly standardized discharge processes as major contributors to LOS. Focusing on improving communication, they then developed a centralized sedation board to offer situational awareness to other members of the sedation team in the ED. This was considered as their primary intervention. Other secondary interventions were a procedure readiness checklist in addition to ready-made discharge materials for families after the completion of sedation. Study participants also were invited to complete an anonymous pre-implementation survey geared toward achieving a better understanding of existing barriers to good communication between members of the sedation team.
The team designated ED LOS as their primary outcome. Additionally, they aimed to improve communication scores as measured in follow-up surveys. Process measures followed included pre-sedation LOS and post-sedation LOS, as well as percentages of sedation survey completion. Balance measures followed included ED LOS for all patients and for those requiring facial laceration.
Before rolling out their interventions, the members of the quality improvement team collected pre-implementation data from the preceding two years. Between September 2013 and September 2015, there were 1116 children in the emergency department who required sedation for long-bone fractures. The sedation board was installed in October 2015, and the rest of the data collected during the study was characterized as post-implementation data. From rollout of the sedation board until the end of the study, there were 1133 patients sedated for long-bone fracture reduction. The team noted that there were no statistically significant demographic differences between the groups that would meaningfully impact the outcome of their study.
Study personnel had aimed to reduce average ED LOS from 360 minutes to 315 minutes after implementation of the sedation board. However, they were actually able to reduce ED LOS to 341 minutes, which represents a 5.8% decrease. Looking more granularly at the phase of care where time was saved, the team documented reduction of pre-sedation LOS from 198 to 187 minutes (5.5% reduction) as well as a reduction in post-sedation LOS from 98 to 89 minutes (9.2% reduction). During this time, their interventions made no impact (adverse or otherwise) on the ED LOS for all patients or in ED LOS for facial laceration. In addressing the fact that they had not met their goal set at the outset of the project (15% reduction in ED LOS), the authors pointed out that they likely were not able to address the key factor that prolonged ED LOS, which was inconsistent availability of personnel and equipment.
Perhaps more impressive than the outcomes from their primary objectives, the authors demonstrated that after deploying the interventions, 92% of survey participants were either “somewhat” or “strongly satisfied” with multidisciplinary communication surrounding ED procedural sedation. This was improved from 68% before Dr. Paydar-Darian’s team made their communication interventions. In fact, the quality team hypothesize that the improvement in ED LOS for this subset of patients likely sprang from improvement in multidisciplinary communication.
In a system where the major culprits for inefficiency are complex—the needs of other patients, availability of hospital staff, the unpredictable timing of cases, and the availability of necessary equipment—it is not surprising that subtle interventions were not able to completely disrupt the problem of prolonged ED LOS. However, as the authors point out, it is heartening that even small changes that are within our grasp can still make a positive difference for provider teamwork and for patient experience. The authors are to be commended on their demonstration of teamwork—both amongst themselves within their training program and between multiple disciplines involved—in the design and publication of their work.