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Implementation and Improvement of a “Pediatric Rapid Assessment Clinic” Model in a Large Community Hospital

Sierra Barrett1, Nicole Archer2, Sean Robinson2, Rebecca Swartz2, Dr. Madan Roy2,3, Dr. Rafi Setrak3, Madelyn P. Law1

1 Brock University, 2 McMaster University, Michael G. DeGroote School of Medicine, 3 Niagara Health System

CONTEXT

•  The goal of the Pediatric Rapid Assessment Clinic (PRAC) is to reduce <48 hour avoidable pediatric admissions to the St. Catharines hospital by 25% by the end of December 2015.

•  We aim to continually improve the clinic process in order to bring the appropriateness of referral to 100% with the goal of decreased hospital admissions and length of stay, and enhancement of overall patient/family and care provider experience.  

•  In response to rising pediatric admission rates, hospitals are considering the benefits of ambulatory care models, such as rapid assessment clinics, as a “safe, efficient, and acceptable alternative to inpatient admission.”1

•  A rapid assessment clinic for acute cases may help to facilitate early hospital discharge by providing reliable follow-up.2 Furthermore, rapid assessment clinics may allow for a shorter and more efficient “patient journey” through the healthcare system and may help to improve patient and staff satisfaction levels.3,4

•  Implementation of a similar pediatric rapid assessment clinic model in the United Kingdom resulted in a reduction in avoidable emergency department (ED) admissions.5

•  The Pediatric Rapid Assessment Clinic (PRAC) is situated within the St. Catharines Site (SCS) of the Niagara Health System (NHS). The clinic serves five EDs and Urgent Care Centres across the Niagara Region (Ontario), with a geographic population of nearly 500,000.

1. Ogilvie, D. (2005). Hospital based alternatives to acute paediatric admission: a systematic review. Arch Dis Child, 90(2), 138-142. 2. Armitage, M., & Raza, T. (2002). A consultant physician in acute medicine: the Bournemouth Model for managing increasing numbers of medical

emergency admissions. Clin Med, 2(4), 331-333. 3. Blair, M., Gore, J., Isaza, F., Pajak, S., Malhotra, A., Islam, S., ... & Lachman, P. (2008). Multi-method evaluation of a paediatric ambulatory care unit

(PACU): impact on families and staff. Arch Dis Child, 93(8), 681-685. 4. Williams, L., Fryer, J., Andrew, R., Powell, C., Pink, J., & Elwyn, G. (2008). Setting up a Paediatric Rapid Access Outpatient Unit: views of general

practice teams. BMC Fam Pract, 9(1), 54. 5. Coleman, H., & Finlay, F. (1996). The rapid access paediatric clinic: a way to reduce inappropriate admissions to hospital. Prof Care Mother Child,

7(6), 157-159. 6. Langley, G. J., Moen, R., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: a practical approach to

enhancing organizational performance. John Wiley & Sons.

1. This project is a collaboration of an multi-disciplinary team of medical students, physicians, nurses, nurse managers, and quality improvement specialists.

2. This project followed the Model for Improvement from the Institute for Healthcare Improvement6

AIM

RESULTS

METHOD

PROCESS MAP & INTERVENTIONS CONCLUSIONS

REFERENCES

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PDSA #5

Figure 1: Annotated run chart – Proportion of PRAC patients who were appropriately referred Major PDSA Cycles are numbered and described in the Process Map.

3. Pediatric admissions data from 2013-2014 was examined to determine potentially avoidable admissions and create criteria for referral to target this population (Table 1).

4. Clinic was opened November 17th, 2015 and runs weekday mornings (5 appointments/day).

5. A Daily Appointment Calendar was implemented in January 2015 for attending pediatricians to record data for process measures.

ELIBIGLE INELIGIBLE

•  Patients between 0 and 17 years of age

•  Acutely ill but stable

•  Requiring <48 hour follow-up from an ED visit

•  Requiring follow-up from an inpatient stay

•  Children requiring routine outpatient services

•  Same-day referrals

•  Patients followed by a pediatrician for an ongoing condition

•  Surgical consults or mental health/behavioural issues

Table 1: PRAC Referral Criteria

BALANCING MEASURES

•  Time of referral

•  Patient satisfaction

•  Staff satisfaction

•  Cost-saving potential

APPROPRIATENESS OF REFERRAL was determined by the attending pediatrician and recorded in the daily appointment calendar. The proportion of referrals meeting the criteria has improved over time to 100% in the month of September as indicated by the run chart in Figure 1.

PATIENT COMPLIANCE has improved over time from a no-show rate of 12% in January, 2015 to 6% in September, 2015.

# OF REFERRING PHYSICIANS has decreased steadily over time from 28 physicians referring in the month of January, 2015 to 15 in the month of September, 2015. There is a core group of physicians referring consistently from the SCS ED. There has also been an increase in physicians referring from other sites as well as outpatient clinics over time.

The PRAC has been successful thus far in providing an alternative to ED admissions for pediatric patients in the Niagara Region.

LESSONS LEARNED

•  Identified 8 major diagnoses of PRAC patients: (1. Pneumonia 2. Viral Gastroenteritis 3. Upper Respiratory Tract Infection 4. Other Viral Infection 5. Bronchiolitis 6. Asthma 7. Seizures 8. Syncope)

•  Demand for the clinic is expected to be much higher in the winter season (October-April)

•  “PRAC not able to see patients soon enough” and “Uncertainty of criteria for appropriate referrals” are both factors still deterring referral (indicated by ED physician satisfaction surveys).

•  Several complex factors affect the study of admission rates to this ED: - Overall ED admission rates in the province are continually increasing. - The SCS is a new hospital and was opened April, 2013 limiting comparative data available. - Pediatric patients enter the ED and UCC at all five sites however St. Catharines is the only site with a pediatric department.

NEXT STEPS:

•  Aim to improve physician engagement by using narratives from core PRAC referring physicians and attending pediatricians to increase amount of appropriate referral.

•  Strategizing for high-use winter season in order to ensure appointments are only made <48 hours after ED visit (<72 hours for Friday visits)

•  In the process of acquiring NHS admissions data to analyze outcome measures and determine how the project has progressed towards the aim of reducing avoidable ED admission.

PROCESS MEASURES

•  Appropriateness of referrals

•  # of physicians referring patients

•  # of no-shows

OUTCOME MEASURES % decrease in:

•  Pediatric admissions

•  Readmissions

•  Length of stay

Appointment booked manually (St. Catharines Site)

Patient meets criteria for PRAC referral

Patient receives information form from ED Physician

Patient enters ED and is triaged

Patient contacted the next day with appointment time

Patient arrives and registers at main registration in

SCS lobby

Patient taken to wait before clinic in 4th floor

waiting room

Patient seen by pediatrician (30 min appointment)

Patient discharged or admitted to inpatient unit

Pediatrician deems referral in/appropriate based upon

criteria

#1: Moved registration from Main lobby to the 4th floor clinic area. January 12th, 2015

#2: Manual appointment booking at St. Catharines Site changed to Meditech central electronic booking at the Welland site. February 16th, 2015

#4: Referring physicians now receive a letter indicating whether or not their referral met criteria. May 14st, 2015

#5: Referral criteria clarified and communicated to referring and attending physicians. August 1st, 2015

#3: Referring physicians now receive a letter indicating when a patient did not attend an appointment. February 26th, 2015

CURRENT PROCESS MAP October, 2015

INITIAL PROCESS MAP November, 2014

MAJOR PDSA CYCLES OVER TIME

Patient meets criteria for PRAC referral

Appointment through electronic central booking

(Welland Site)

Patient leaves with information and appointment booking

in-hand

Patient arrives and registers at 4th floor registration (SCS)

Patient seen by pediatrician (30 min appointment)

Patient discharged or admitted to inpatient unit

Pediatrician deems referral appropriate or not based

upon criteria

Letter sent to referring physician to inform whether the referral was appropriate

or not

If felt that the referral was in fact appropriate when

deemed inappropriate – report to Chief of Pediatrics

Patient enters ED and is triaged

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