31 - A Quality Improvement Initiative to Decrease Length of Stay for Pediatric Patients with Uncomplicated Fractures in the Pediatric Emergency Department

Poster Number: 31
Publication Number: 31.406

Ammarah U. Iqbal, Yale-New Haven Children's Hospital, New Haven, CT, United States; Lawrence Siew, Yale School of Medicine, New Haven, CT, United States; Adrienne Socci, Yale School of Medicine, New Haven, CT, United States; Gauthami Soma, Yale School of Medicine, West Hartford, CT, United States; Gunjan Tiyyagura, yale university school of medicine, New Haven, CT, United States

Background: Many pediatric extremity fractures presenting to emergency departments (EDs) for care may be managed using non-rigid splints, with outpatient follow-up for definitive orthopedic care. Non-rigid immobilization with casting for certain fractures, such as distal forearm buckle fractures, has been shown to lead to improved functional recovery, treatment costs, and pain control. In our tertiary care ED, most children with uncomplicated extremity fractures were being evaluated by orthopedists and casted prior to discharge, leading to unnecessary casting and increased length of stays (LOS).

Objective: The global aim of this study was to improve care of children presenting with uncomplicated extremity fractures in our pediatric ED (PED). Our primary objective was to decrease the mean LOS for these children by 25% from 170 minutes to 130 minutes within 12 months using quality improvement methods. We examined the 7-day PED return rate as a balancing metric.

Design/Methods: Using the model of improvement approach, we formed a multidisciplinary team of providers. We interviewed parents, providers and residents and found that key contributors to LOS included bedside orthopedics involvement and lack of PEM staff knowledge of splinting (Figure 1.) Process mapping and interview data informed the key drivers of our project, which included development of standardized workflow and appropriate provider knowledge in fracture management (Figure 2). Using the Plan-Do-Study-Act (PDSA) methodology, interventions included development and dissemination of a standardized workflow for uncomplicated fractures, training in splinting, and improved access to prefabricated splints.

Results: We measured the mean LOS of children in the PED with specified uncomplicated extremity fractures using a process control chart, using cohorts of 5 patients (Figure 3). Prior to the start of the study, the mean LOS was measured at 170 minutes. Evidence of special cause variation was identified in 3 months after initiation of interventions, with a shift in mean LOS to 144 min. Narrowed control limits were indicative of a decrease in variation of the process. There was no change in return visits to the ED throughout the study period.Conclusion(s): Quality improvement efforts to improve evidence-based management of uncomplicated orthopedic fractures by encouraging the use of non-rigid immobilization during initial presentation in the PED significantly improved LOS for these patients.
Ammarah U Iqbal CVAmmarah U Iqbal Curriculum Vitae.pdf
Figure 2. Key Driver Diagram