Department of Pediatrics, University of California, Davis, Sacramento, California;
University of California, Davis Children's Hospital, Sacramento, California.
Hosp Pediatr. 2020 Mar;10(3):214-221. doi: 10.1542/hpeds.2019-0158. Epub 2020 Feb 12.
Discharge of hospitalized pediatric patients may be delayed for various "nonmedical" reasons. Such delays impact hospital flow and contribute to hospital crowding. We aimed to improve discharge efficiency for our hospitalized pediatric patients by using an iterative quality improvement (QI) process.
Opportunities for improved efficiency were identified using value stream mapping, root cause, and benefit-effort analyses. QI interventions were focused on altered physician workflow, standardized discharge checklists, and physician workshops by using multiple plan-do-study-act cycles. The primary outcome of percentage of discharges before noon, process measure of percentage of discharges with orders before 10 am, and balancing measures of readmission rate, emergency department revisit rate, and parent experience survey scores were analyzed by using statistical process control. The secondary outcome of mean length of stay was analyzed using tests and linear regression.
Implementation of our interventions was associated with special cause variation, with an upward shift in mean percentage of discharges before noon from 13.2% to 18.5%. Mean percentage of patients with discharge orders before 10 am also increased from 13.6% to 23.6% and met rules for special cause. No change was detected in a control group. Adjusted mean length of stay index, 30-day readmissions, and parent experience survey scores remained unchanged. Special cause variation indicated a decreased 48-hour emergency department revisit rate associated with our interventions.
An iterative QI process improved discharge efficiency without negatively affecting subsequent hospital use or parent experience. With this study, we support investment of resources into improving pediatric discharge efficiency through value stream mapping and rapid cycle QI.
由于各种“非医学”原因，住院儿科患者的出院可能会被延迟。这种延迟会影响医院的流程，并导致医院拥挤。我们旨在通过迭代质量改进 (QI) 流程来提高住院儿科患者的出院效率。
使用价值流图、根本原因和效益-努力分析来确定提高效率的机会。QI 干预措施侧重于改变医生的工作流程、标准化出院检查表以及通过多次计划-执行-研究-行动循环进行医生研讨会。主要结果是中午前出院的百分比、上午 10 点前下达出院医嘱的百分比，以及再入院率、急诊科复诊率和家长体验调查评分的平衡指标，通过统计过程控制进行分析。平均住院时间的次要结果使用 t 检验和线性回归进行分析。
我们干预措施的实施与特殊原因变化相关，中午前出院的平均百分比从 13.2%上升到 18.5%。上午 10 点前下达出院医嘱的患者比例也从 13.6%增加到 23.6%，并符合特殊原因规则。对照组没有发现变化。调整后的平均住院时间指数、30 天再入院率和家长体验调查评分保持不变。特殊原因变化表明与我们的干预措施相关的 48 小时内急诊科复诊率降低。
迭代 QI 流程提高了出院效率，而不会对后续医院使用或家长体验产生负面影响。通过这项研究，我们支持通过价值流图和快速循环 QI 投入资源来改善儿科出院效率。
