Pediatric Ward Discharge Quality Improvement

Study Overview
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Brief Summary
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This study will utilize an iterative quality improvement process to identify and address delays in the pediatric hospital discharge process.

Detailed Description
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Hospital crowding has been associated with increased hospital length of stay in pediatric populations and adverse outcomes in adult populations. This study focuses on a 36-bed general pediatric inpatient care unit whose occupancy has seen exponential growth over the past several years. With the growth in patient population, the study hospital is experiencing increasing difficulty with hospital crowding, particularly during key times of year, such as the winter viral respiratory season. During these times, pediatric patients may experience high emergency room wait times, and admitted patients may be required to board in the emergency room or post-anesthesia care unit while they await an inpatient bed. Lack of inpatient bed availability has also, at times, required cancellation of surgical cases and denial of outside hospital patient transfers to the institution, resulting in inconvenience to patients and delays in care. The pediatric hospital discharge process has come under particular scrutiny as an area in which both the efficiency and the effectiveness of patient care can be improved. Currently, around 10% of patients ready for discharge in a given day from the general pediatric hospitalist service are discharged prior to noon, freeing up this bed space for a new patient. While for some patients, discharge is postponed for medical reasons, others must remain in the hospital for non-medical delays. For example, they may remain hospitalized because they have not yet been seen by a physician, their medications are not available for pick-up from the pharmacy, or they do not have transportation from hospital to home. Several studies in pediatric populations have shown that quality improvement processes can improve discharge efficiency without compromising care quality or patient/family satisfaction. The investigators aim to determine if an iterative quality improvement process can reduce barriers to discharge and therefore decrease pediatric patients' length of stay. They will simultaneously analyze several secondary outcomes to evaluate patient flow, patient/family satisfaction, and subsequent hospital utilization to evaluate for unintended consequences of the interventions.

Official Title
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Pediatric Ward Discharge Quality Improvement

Conditions
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Pediatric Hospitalization

Intervention / Treatment
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* Procedure: Pediatric discharge process interventions


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Children or young adults less than 21 years of age admitted to the University of California Davis Children's Hospital Pediatric Hospitalist Service on the general pediatric inpatient ward Exclusion Criteria: Adults greater than 21 years of age, including those unable to consent Pregnant women Prisoners Children admitted to other services (i.e. Ear, Nose and Throat Surgery, Pediatric Surgery, Pediatric Gastroenterology, Trauma, Pediatric Nephrology, Pediatric Hematology/Oncology, Pediatric Intensive Care Unit, Neonatal Intensive Care Unit, Newborn Nursery, etc.)

Ages Eligible for Study
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Maximum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Pediatric discharge process intervention<br>All patients hospitalized on the pediatric ward under the pediatric hospitalist service will participate in pediatric discharge process interventions. | Procedure: Pediatric discharge process interventions<br>* As this is an iterative quality improvement process, interventions will be evidence-based and chosen to test effectiveness for addressing areas of discharge bottlenecks or inefficiency within our specific hospital's context. Examples of possible interventions may include implementation of a discharge risk assessment (as in Statile et al, Pediatrics 2016), institution of a medications-in-hand policy on hospital discharge (as in Sauers-Ford et al, Pediatrics 2016), or initiation of a ward discharge coordinator who will help coordinate outpatient follow-up for patients. Interventions will be implemented in a stepwise fashion, utilizing successive plan-do-study-act cycles, with a minimum 2 month period between interventions to monitor outcomes.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Length of stay index | Length of stay index is a metric that is calculated by Vizient and compares a patient's hospital length of stay to national averages, taking into account the patient's diagnosis, severity of illness, and disease complexity. | Time from admission to discharge through study completion in 1 year. | 
| Percentage of patients discharged before 1200 | Percentage of pediatric hospitalist patients who are discharged before noon on the day they are eligible for discharge. | Discharge time for each patient within a 24 hour period on day of discharge. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Readmission | Same hospital 30 day readmission rate | 30 days | 
| Emergency department re-visit | Same hospital 7- and 30-day emergency room revisit rate | 7 and 30 days | 
| Patient satisfaction | Patient/family hospital discharge satisfaction scores, as measured on the Child Hospital Consumer Assessment of Healthcare Providers and Systems (CHCAHPS), which is sent to each family after their child is discharged from the hospital. | Mailed to families following hospital discharge through study completion in 1 year. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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hospital discharge, quality improvement, transition of care, pediatric