From the Department of Pediatrics, Divisions of General Academic Pediatrics and Pediatric Emergency Medicine for Saint Louis University.
SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO.
Pediatr Emerg Care. 2021 Dec 1;37(12):e861-e865. doi: 10.1097/PEC.0000000000002261.
Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours.
Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures.
The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients.
By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.
直接入院是指将患者直接送入病房，而不经过急诊等常规入院途径。如果直接入院安排不当，可能会导致快速响应激活、心肺复苏和意外转入儿科重症监护病房（PICU），这与更高的死亡率和更长的住院时间相关。该项目的目的是通过减少 6 小时内直接入院患者转入 PICU 的比例来提高直接入院流程的安全性。
利用改进模型，组建多学科团队，改进我们的筛选流程，减少 6 小时内直接入院患者转入 PICU 的情况。我们的基于急诊的直接入院流程包括筛选生命体征（体温、心率、呼吸频率、血压和脉搏血氧饱和度）和儿科早期预警评分。经过五个计划-执行-研究-行动循环，重点关注角色定义、改进记录、转诊机构和家庭意识、急诊室内可视化管理以及合作伙伴 EMS 和转运提供商的教育。主要结果是直接入院后 6 小时内转入 PICU。全面筛查的依从性是一个过程性指标，直接入院人数是一个平衡性指标。使用统计过程控制图和运行图来跟踪这些指标。
2014 年 1 月至 2018 年 6 月底数据收集结束期间，共有 3070 名患者直接入院。整个医院的筛查方案依从性从 56%提高到 80%以上。未预料到的直接入院转入 PICU 的比例从基线的每 98 例患者 1 例降至特殊原因的每 1126 例患者 1 例。
通过利用 QI 方法学，我们的团队能够实施和维持一个更一致、更易于记录的直接入院流程，提高了患者的安全性。我们的研究表明，可靠和一致地筛查直接入院患者可以降低转入更高级别护理的比例。
