emergency pediatric group department … · 2010-03-29 · admission/transfer guidelines ... rapid...

EMERGENCY PEDIATRIC GROUP

DEPARTMENT MEETINGJuly 11, 2007

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Announcements

New fellowsNew Hires• Parmi Suchdev - start date July 1, 2007• Tracy Merrill - August 14, 2007• Tiffany McKinnie - August 14, 2007• Susan Goldberg - October 1, 2007

PEM candidate• Amita Schroff - Long Island Jewish• Sephora Morrison - Children’s Memorial-

Graduating June 2008Salmonella Wandsworth outbreak• Veggie booty bags implicated

Education on medical photographyDr Cornish will present faculty productivity

Volume Indicators

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Census: 3 year CHOA-HS

2500300035004000450050005500

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2005 data 2006 data 2007 data

Census: 3 years: CHOA-ECH

2,0002,5003,0003,5004,0004,5005,0005,500



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Admissions: CHO

0

50

100

150

200

250

300


2005 data 2006 data 2007 da

Admissions: CHOA-ECH

0100200300400500600



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Walkouts: CHOA-H

0

50

100

150

200



Walkouts: CHOA-ECH

0.0%0.5%1.0%1.5%2.0%2.5%3.0%



Hughes Spalding

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Hughes Spalding

Staffing – 2 nurses and 2 techs have been hiredIssues with transfers –• No ortho transfers will be accepted at HS• If CHOA does not give priority to a transfer, let Dr.

Khan knowQuestions about changes slated over the next monthsNew VP: Julia JonesPAC moonlighting• Looking for volunteers

9a-3pSeeing fast track patients

Alert• New interns: provide close supervision• Do not leave the ED/ UC without informing the senior

resident and charge nurse (even for a few minutes)• Prehospital medications cannot be given to patients

once they arrive in the ED

Division of Pediatric Emergency Medicine

Physician education: changes at Hughes Spalding

June 23, 2007July 11, 2007

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HSOC Patient Safety Charge

Develop a plan which ensures safe implementation of the inpatient service plan recommendations for Hughes Spalding

which meets the quality and safety standards of Children’s and is within the financial constraints of the organization.

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Working Team Goals

IP Working Team

Goal: To develop a detailed plan for the stabilization of children who are too sick to be admitted to HS and to identify the plan for their transportation to Egleston or Scottish Rite.

ED Working Team

Goal: To identify admission/transfer guidelines for HS inpatients and develop the details of a hospitalist program to support the patients who are admitted. To define guidelines and procedures for potential critical inpatient clinical scenarios.

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IP Working Team MembersWorking Team Leads:Dr. PettignanoDr. Graham

Working Team Members:Dr. FlowersDr. TaylorDr. KeyesDr. Kohrt

Others Consulted:Dr. MillerDr. DelgadoDr. MooreDr. DunstonDr. PettitDr. StollDr. Tyler-Hill)

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ED Working Team MembersWorking Team Leads:Dr. KhanDr. McCrory

Working Team Members:Dr. FortenberryLinda Cole

Consulting Members:Dr. PetrilloDr. KingDr. GooDr. SpizmanCyndie RobersonKevin Wall

Recommendations

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Admission and transfer guidelines

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Basis for decisions

No ICU

Ability to safely care for the patient

On-going evaluation to expand or contract guidelines

Implementation of these guidelines may initially decrease admissions

Centralized dispatch can offload less acute patients from other campuses to Hughes Spalding where appropriate

ED patients who do not meet criteria for admission to HS and would

require transfer

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General

Patients who require a higher level of care (medications or resource needs) in excess of that provided in the general patient care unitat Hughes Spalding• Patients who require one-on-one nursing

care• Patients who require specialty care not

provided at Hughes Spalding

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SpecificRespiratory• O2 requirement ≥ 50%, to maintain SpO2 ≥ 92% at the

time of ED disposition• More than one reported or witnessed apnea with color

change• Intubated patients• BiPaP / CPAP requiring ≥50% O2 and/or more then one

dose of sedation• Patients with immature tracheotomy (≤ 2weeks)• Asthma patients requiring ketamine infusion

Neurological• Acute onset altered mental status requiring continuous

monitoring and/or > q2hr neuro-checks• Intracranial bleeds, masses, CVA’s, increased ICP• Ventricular shunt patients with shunt related problems• Post-op neurosurgical complications

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Specific

Cardiovascular• Hemodynamic instability not improved with fluids

alone• Patients requiring inotropes, vasodilators, anti-

arrhythmics, cardioversion• High risk cardiac patients with complex

congenital conditions, shunts, pacemakers, open thoracotomy

• Patients with acute myocardial/ pericardial disease

Hematologic/Oncologic Diseases• All active oncology patients• All unstable hematology patients

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Specific

Gastrointestinal Diseases

• Acute GI bleed with hemodynamic or respiratory instability

• Patients requiring endoscopy for FB removalSurgical

• All patients requiring acute surgical intervention• All major trauma patients with unstable and/or life

threatening injuriesRenal

• Patients with signs of acute renal failure• Patients requiring hemodialysis, peritoneal dialysis

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To be developed:

Clinical Guidelines• To be developed by the ED physicians• Include permissible length of stay and extent of

interventions prior to assigning disposition• Including but not limited to the following disease

processesAsthmaBronchiolitisDKADehydration with acidosis and/or hypotensionIngestionsAcute abdomenIntussusceptionAltered mental statusApnea with color change

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Approach to a patient deteriorating on the floor

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Approach to Clinically Worsening Patient

P a t i e n t a d m i t t e d t o G e n e r a l P e d ia t r ic s F lo o r

C h a n g e in p a t ie n t s t a tu s

C l in ic a l c h a n g e b u t n o t u n s ta b le C a r d io p u lm o n a r y i n s ta b i l i t y N o t i f y s e n io r r e s id e n t C o d e b lu e U n a b le to r e s p o n d R e s p o n d s o r C o d e t e a m * * r e s p o n d s n e e d f o r p r e l im in a r y e v a lu a t io n e v a lu a t io n R R T * e v a lu a t i o n P a t i e n t s t a b i l i z e d i n te r v e n t io n p r n R a p id r e s p o n s e t e a m * H o s p i t a l i s t n o t i f i e d N o t i f y C o d e b lu e H o s p i t a l i s t E v a lu a t io n T r a n s f e r b a s e d o n D i s c u s s io n o f g u id e l in e s f u r th e r C o d e T e a m * * i n t e r v e n t io n /d i s p o s i t io n C a l l r e s id e n t S u g g e s t s i n t e r v e n t io n

F u r th e r In te r v e n t io n T r a n s f e r o r c o n t in u e d c a r e b a s e d o n g u id e l in e s N o t i f y h o s p i t a l i s t o f r e c o r d o r h o s p i ta l i s t o n c a l l

T r a n s f e r o r c o n t in u e d c a r e b a s e d o n g u id e l in e s

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A dedicated hospitalist group at HS

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Why a hospitalist program at HS?Dedicated patient care Expertise in disease managementComfort with identified patient populationImproved quality, error reductionImproved patient satisfaction

Critical components needed at HS:Board Eligible/Certified in Pediatrics or a Pediatric Sub-SpecialtyDedicated hospitalist 24/7

• (i.e. when assigned to hospital, they do not have any other clinical responsibilities).

Minimum of 3 months of clinical service per yearCall from home, return when needed

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Hospitalist Program

Key components still to be determined:

Hospitalist job descriptionNumber of teamsMedical school representationNumber of FTE’sAcceptable call scheduleDetermine core competencies in

Disease managementProcedures

Develop education componentDevelop Q/I program

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Critical Success Factors

Keeping the best interest of the patient as our driving forceCreative thinking and flexibilityProvider buy-in (MD’s, nurses, respiratory others)Ensuring provider training and competency on an ongoing basisFlexible nursing/RRT model to accommodate children needing a greater nurse/RRT to patient ratioContinued reevaluation of admission and transfer guidelinesSuccessful QI program

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IP Critical Success Factors..Contd

Dedicated inpatient providers

In depth understanding of:Admission criteriaTransfer criteriaApproach to the worsening patient

Inpatient MD comfort with saying “no” to the ED

Inpatient MD returning to hospital to evaluate the “sick or sicker” childhelp with stabilization and transfer

ED MD comfort with decision to transfer

Acceptance and buy-in of key physicians and leaders at SR and EG with regard to HS’s transfer criteria and policies.

Algorithm for Transfer site selection

Implementation July 1, 2007

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PATIENT DOES NOT MEET ADMISSION CRITERIA or

NEEDS EXCEED HS ED RESOURCES

New / unassigned Patient

The patient has campus-specific needs?

(Cardiac/ECMO/Transplant/Rehab)

Campus based subspecialty patient with related illness

No Yes

No

Yes

What day is it?

Odd Even

Call SR Call EG

PICU admission

Transfer to designated ED

Yes - but with new condition

requiring campus-specific

transfer

EG-based MD

Call SR Call EG

Call specific Children’s facility

for transfer SR-based MD

No beds

Floor admission

Hold in HS ED, till bed available at designated hospital

No beds

ED to ED transfers

To designated hospital

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ED physician and resident staffing

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ED physician staffing

Current:• BC/BE Pediatric Emergency Medicine coverage 7am to

2am

• Fellow coverage- 2am to 7am

• During peak hours 12-16 hours of coverage with urgent care physician

Physician Staffing under Patient Safety Plan:• Transition to 24-hour coverage with Pediatric Emergency

Physicians

• Reevaluate staffing needs every 4-6 months

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Other providers

Minimal resident staffing• Four/ shift• One senior pediatric resident

Augmentation of resident staffing with urgent care NP’s or PA’s• Budgeted for 3.4 FTE’s

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Non-physician Staffing and Skills

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Staff Skills and Coverage

Nursing• Education focused on stabilization and monitoring of

critical patients

Respiratory therapy• Coverage

Minimum of 1 RT in ED 24/7Float RT during peak times

• Education (slated to be completed by July 2007)IntubationVentilator managementLMA placement

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HS Hospital-wide response to “Code Blue”

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Response to “Code Blue”

Development of a team concept

ED physician and ED nurse responds to codes

Hospitalist responds in person andHelps in stabilization on arrivalProvides post-stabilization monitoringUpdates parents/ guardianTalks to accepting physicianArranges transport

Other physicians/ staff to ED to monitor and manage ED patients

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Screening In-coming Transports to Hughes Spalding

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Plan

Children’s Central dispatch (once created) to • direct appropriate EMS traffic to HS• Direct inappropriate EMS traffic away from HS

Unstable patients to HS only if • HS is the nearest facility or• BOTH EG and SR are on ED saturation

EMS transports and inter-facility ED transfers• HS will not accept

Unstable patients, unless as aboveIntubated patientsPatients requiring cardiac, neurosurgical, surgical, orthopedic servicesPatients who obviously do not meet admission criteriaPatients meeting major trauma criteria as defined by ACS guidelines

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Dedicated HS transport team

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Transport PlanKey Components

Pediatric Transport Team:• RN, RCP & EMT-P

Coverage 24/7/365

Integrated into current Children’s transport system

Unit based at HS

Medical Control: Receiving MD is online Medical Control

Staff, when available, will assist in PEC

Benefits of Plan:• Improves coverage of south and west section of metro area

• More easily accessible for HS transfers

• Will transport patients from HS to CT scanner at Grady when needed

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ED Plan Critical Success Factors

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ED/Transport Critical Success Factors

Physicians• Acceptance of HS patients by the physicians at EG and SR• Acceptance of direct admissions to EG and SR by

subspecialists and hospitalists• Development of the hospitalist model at HS

Patients and Families• Availability of non-emergent transportation to EG and SR

for patients and families• Social services at all three sites to meet the needs of this

populationOther• Critical care and floor bed availability at EG and SR• CR machine for copying radiographs for transfer patients• Optimal resident and practitioner staffing to support the

attending physician coverage• Team approach to “code blues”• Cat Scan transport team: composition to be determined• Children’s response gives preference to HS transfers

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Does plan fit within 2008 budget?

Most of the patient safety plan developed was able to be fit into the financial parameter of the 2008 budget.

In order to transition to 24/7 PEM coverage in the ED, a cost of $200,000 annually will be incurred and will be incremental to the 2008 operating budget.

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Quality Improvement ProgramThe following indicators will be monitored and closely

reviewed to ensure patient safety and quality;

• ED admissions and transfers

• Adherence to admission criteria and inpatient volumes

• Origin of admissions: ED, direct admit (source)

• Transfers

• Activation of rapid response team

• “Code blue”

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TimelinesJune 28, 2007• Dr. McCrory resigns

July 1, 2007• Implementation of transfer algorithm• Pediatric orthopedic clinic closes at Grady• Only closed reductions and consultative orthopedic

services provided at HS (these patients will get follow up in the adult orthopedics clinic at Grady)

• PICU beds reduced to 3 beds (low census, insufficient nurses)

• PICU attendings: Drs Pettignano, Paradisis, Stockwell, Hebbar, Petrillo

• Dedicated hospitalists for the general pediatric serviceJuly 16, 2007• free commuter van service for patients and families with

appointments or services at EG or SR

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Timelines…contdAugust 1, 2007• Children’s response unit based at HS 24/7

September 1, 2007• PICU closes• New admission and transfer guidelines implemented• All admissions will be to the 18 bed 3rd floor• An additional overflow 5 beds will be available on the

2nd floor which will be closed down• ED attending moonlighting shift added 2a-7a

October 1, 2007• 24/7 ED coverage at HS and reorganization of the EG

and HS fellow coverage

Egleston

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EglestonStaffing – all respiratory positions have been filledTrauma Update – number of traumas were average for JuneFast track report –• We are meeting goals 25% of the time• Compare observational things to see what S.R. does

right so that we can improve and get patients in and out in 90 minutes or less.

• If you have ideas or suggestions, contact Roshni Patel

Calling out physicians – use it wisely

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Egleston

Master Facilities Building Update• Lab moves this week• Conference center moves June 12• Blood bank moves next week• Morgue moves next week• In-patients will be relocated June 23 and

24.

We will still be responding to codes until further notice. Please check your email for updates.

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Faculty Issues

Grady privileges MUST be maintained to keep malpracticeTDJ update - use by August 31, 2007Need a PEM and an UC physician to coordinate recruiting

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Basic Non-Clinical Requirements

<15.1% >15.1%Scholastic Oversight Cttee 4

Req office time 12 8Req. fellows conf 8 12

Req. EPG mtgs 6 6AVU's 92 80

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Office Day responsibilities

Effective date: July 1, 20079a-3pSelf schedulingED BU Chart reviewsCommittee workAttendance at meetingsSpecial projectsCan schedule teaching activities

emergency pediatric group department … · 2010-03-29 · admission/transfer guidelines ... rapid...

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