By Stacey Kusterbeck
Preventable, serious safety events related to discharge from the ED motivated clinicians at Boston Children’s Hospital to implement a standardized process. “We follow and review all events locally within the department of emergency medicine, which can include some return visits,” says Niloufar Paydar-Darian, MD, instructor of pediatrics at Harvard Medical School.
The emphasis is on family engagement and multidisciplinary communication. “In the past, we focused on improving admissions or transfers. But those patients are remaining in the realm of care of medical providers,” Paydar-Darian says.
In contrast, discharged patients are making a complex transition — from the ED to home, to undergoing follow-up care in the outpatient setting. “For providers, it involves recognizing that the patient is ready for discharge, but also that the family has the resources to care for the patient at home,” Paydar-Darian explains.
The goal was to redesign the process to be simple and effective, to put the patient in the best position to make the transition safely. These changes were made:
• ED nurses and providers use a discharge checklist. This ensures there are no outstanding labs, that vital signs were obtained within 60 minutes before discharge, and that the patient has received all the prescriptions needed.
• ED nurses and EPs meet briefly to be sure everyone agrees the patient is ready for discharge. “For us, a big-picture goal was to create a thoughtful moment before the patient goes home,” Paydar-Darian says.
Providers pause to consider the data, such as vital signs and lab results, and ensure the family understands the plan and with whom to follow up. For example, if a child presented with an elevated heart rate that was attributed to fever, providers ensure the heart rate returned to normal. Sometimes, a child’s vital signs did not return to normal, or lab tests return indicating the need for further workup. In those cases, providers change the disposition plan for further work-up in the ED, observation, or admission to the hospital.
• Emergency providers use scripting to review discharge instructions with families. ED providers cover the child’s diagnosis, medications, or treatments; with whom to follow up and when; reasons to return to the ED; and invite the family to ask additional questions.
The new process eliminated preventable serious safety events related to discharge, without extending length of stay.1 “There are so many pieces to keep track of that it really requires an easy-to-follow process,” Paydar-Darian says. “Otherwise, we are at risk for missing something that could lead to the patient having to return to the ED.”
REFERENCE
1. Paydar-Darian N, Stack AM, Volpe D, et al. Improving discharge safety in a pediatric emergency department. Pediatrics 2022;150:e2021054307.
Preventable, serious safety events related to discharge from the ED motivated clinicians at Boston Children’s Hospital to implement a standardized process. Staff follow and review all events locally within the department of emergency medicine, which can include some return visits. The emphasis is on family engagement and multidisciplinary communication.
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