Hurley Medical Center / University of Michigan

A QI Initiative to Improve Pediatric Discharge Vital Sign Documentation in a Community Emergency Department

Project Lead: Courtney Mangus, MD

Project AIM(s): Within 12 months, we will improve the percentage of pediatric patients discharged from HMC ED with documented discharge vital signs, when clinically indicated, from 30% to >80% to enhance timely and accurate diagnosis of pediatric sepsis and reduce patient harm.

Narrative Description

We aimed to develop a sustainable, system- wide intervention that will result in repeat vital signs being consistently performed prior to discharge in >80% of pediatric patients at risk for sepsis. We define children at risk for sepsis as those who trigger currently accepted screening criteria defined by age-based vital sign abnormalities (commonly referred to as SIRS- Systemic Inflammatory Response Syndrome criteria) applied at ED triage, embedding the criteria in the electronic health record (EHR). We followed this with cycles of structured clinician education at stakeholder and department-wide meetings.

The largest challenge to our intervention implementation and success was the many effects of the COVID-19 pandemic. Initially, our IT support and other administrative infrastructure was justifiably prioritizing EHR updates and administrative attention on items related to the pandemic (prevention, diagnosis, management, etc). In the last year, the other main challenge has been related to staffing, particularly in nursing. Nurses are a huge component of this project, and our ED at Hurley saw tremendous turnover of nursing personnel and continues to face ongoing staff shortages. Without consistent nursing staff in our pediatric ED unit, it has been challenging to keep all personnel apprised of the QI project and their role in its success. Additionally, with the unit being short staffed, there were fewer nurses to physically accomplish the task of repeating vital signs. We found that some families were waiting for vital sign reassessment at the end of their visit while nurses were occupied prioritizing other tasks. Occasionally, families elected to leave rather than wait for reassessment.

We launched several additional PDSA cycles, mostly targeted at staff re-education and re-socializing our measure with new hires. Additionally, we added training for the many categories of learners in our space (medical students, pediatric resident, ED residents, and family medicine residents) at their respective orientations. We are currently, on average, obtaining repeat vital signs in over 70% of children discharged from our ED. We are not yet at 80%, but we continue to work towards this goal. 

Despite the challenges, our intervention continues. The EHR alert remains active and we generate weekly reports on our success to share with nursing staff. Physicians are updated monthly at the staff meeting. We are hoping that when we have a more stable pool of nurses, we can gain more traction as we will be working with a consistent group of people and messaging can be repeated and revised based on our team.

The main aspect of the intervention that could be reproduced at this time is the introduction of an EHR alert notifying clinicians at time of discharge that the abnormal vitals were never repeated. Staff have found this very helpful – in the ED setting clinicians are frequently multi-tasking and overseeing care of many complex patients at once. This simple alert helped our team accomplish safer ED discharges for our pediatric patients.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)
  • Physical environmental or work system factors
  • Health information sharing and accessibility via health IT
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)
  • Emergency department