49 - Implementation of a clinical pathways program to reduce risks associated with emergency department crowding: a quality improvement initiative

Poster Number: 49
Publication Number: 49.407

Caitlin Li, Boston Children's Hospital and Massachusetts General Hospital, Boston, MA, United States; Ashley A. Foster, Massachusetts General Hospital, Boston, MA, United States; Cassie Kraus, MassGeneral Hospital for Children, Boston, MA, United States; Nicole Nadeau, MassGeneral Hospital for Children, Boston, MA, United States

Background: Emergency department (ED) crowding is increasing and threatens patient safety. Clinical pathways are known to reduce variation and improve timeliness of care.

Objective: We developed a clinical pathways program to prevent prolongation of time to critical medication administration in the setting of increasing demand on ED services.

Design/Methods: This project was set in our tertiary pediatric ED located within an adult hospital. Pathways were developed by the study team and representatives from appropriate specialties. Pathways for asthma, anaphylaxis, febrile neutropenia, and fever in patients with sickle cell disease included time goals for critical medication administration; the pathway for diabetic ketoacidosis (DKA) did not. Outcome measures were time to administration of albuterol, epinephrine, and antibiotics respectively. Process measures were number of times pathways were accessed and resident-reported pathways use. Balancing measure was overall return to ED within 72 hours. We completed three plan-do-study-act (PDSA) cycles 1) posted a list of available pathways and a QR code to access them 2) created a link in the electronic medical record that connected to the pathways 3) delivered resident conferences. Measures were analyzed using individual moving range statistical process control (SPC) charts with standard tests for special causes.

Results: Between 7/2020 and 11/2021, ED volume increased from 659 patients/month to a peak of 1697/month; time from ED triage to provider increased from 12 to 35 minutes. PDSA cycles were carried out 12/2020-1/2021. No special causes were identified on SPC charts for time to administration of antibiotics in patients with sickle cell disease/febrile neutropenia or administration of corticosteroids for patients with asthma. The single special cause for epinephrine occurred in a month with a single patient with anaphylaxis. In the DKA control population, average time to insulin administration increased and multiple special causes were identified, indicating that the process was not in control. No special causes occurred in overall rate of return within 72 hours. A year after implementation, 44% of residents reported using pathways on at least ¾ of their shifts and pathways had been accessed 6117 times.Conclusion(s): In our institution, clinical pathways with time-based goals of care were an effective tool in stabilizing time to administration of time-sensitive medications despite rising ED volumes and times from door to provider.
CVCaitlin Li CV_Nov 2021.pdf
Figure 2: SPC charts of outcome measuresA: Median time to corticosteroids in asthma B: median time to antibiotics for patients with sickle cell disease and neutropenia C: median time to epinephrine in patients with anaphylaxis D: median time to insulin in patients with diabetic ketoacidosis