Observing long lines in patient waiting areas, seeing worried faces of parents concerned about the safety of their children, and receiving frequent patient feedback about the pediatric Emergency Department made me curious to explore opportunities to improve the unit.
St. Peter’s TB Specialized Hospital, in Addis Ababa, Ethiopia, was established in 1953 and has been serving the nation as the only tuberculosis hospital for more than four decades. Over the past few years, the hospital grew from a single disease hospital into multi-disciplinary services health institution that includes pediatric medical care.
As stated in the Ethiopian Hospital Services Transformation Guidelines, properly designed and implemented hospital-based emergency medical care services reduces triage and treatment times, increases provider efficiency and staff and patient satisfaction, and improves overall quality of care. Pediatric care is one of the priority health concerns nationally.
A regular patient interview conducted at the hospital to improve service found a significant number of patient complaints about pediatric emergency care. Based on this, our quality improvement team did a clinical audit, which found major gaps in quality of care related to the provision of appropriate triage, comprehensive clinical evaluation, and correct treatment management. These gaps had contributed to the poor child health outcomes in our hospital.
The project goal was to improve the pediatric emergency service score, which measures appropriate triage, justifiable diagnosis, and appropriate management, more than 90 percent. We formed a multidisciplinary QI team, which consisted of a pediatrician, the case leader physician, the head nurse, and two quality officers, to design, implement, and monitor the project. I was an Improvement Advisor for the team.
Team members working together.
The quality improvement team did root cause analysis using a driver diagram and proposed change ideas.
Driver diagram for improving the pediatric emergency care service score.
The team prioritized interventions by ease of implementation and importance. We used Plan-Do-Study-Act (PDSA) cycles to study intervention effectiveness. For data collection, we selected four patient charts using simple random sampling and audited them using checklist. Weekly, the team calculated the outcome measures and fed them to a summary sheet.
One challenging for me was creating an initial curiosity and understanding from the pediatric emergency team about the importance of the QI project. Surprisingly, commitment and dedication of the team significantly improved after the baseline audit findings were presented, and again after they saw the initial results of the interventions.
PDSA cycle ramps for two aims within the project.
For example, one of the major gaps in the baseline assessment was that triage officers often don’t use triage papers. Even when used, sometimes it is incompletely filled. So, we used initial PDSA cycles to observe major problems with the triage papers. We found:
- The triage paper had unnecessary components which can be removed.
- The location of the paper was crowded by many unnecessary data collection forms. Hence the paper was not clearly visible.
- Triage workflow did not match the sequence of triage paper questions.
Then, we modified the triage papers by consulting pediatricians and emergency physicians. We matched the sequence with the workflow, keeping only questions help for emergency management and removing the unnecessary questions on the triage paper.
Next, we tested utilizations of the new modified triage paper. We assessed whether the triage paper was used and the completeness of the paper. We also measured the effect on patient management and patient outcomes.
For individual aims (such as percentage of patients with a completed triage paper), as well as the overall goal of improving the emergency care service score, run charts and Shewhart (control) charts was used to display the data over time.
Measuring the emergency care service score over time.
Lessons from this work include:
- Use data to motivate improvement. Clinical audits play a key role in identifying major gaps in practice. The hospital designed a standard clinical audit tool that assesses input, process, and outcomes. These audits are conducted regularly by each department’s quality improvement team. Data also plays a key role as an entry into discussion with the clinical team.
- Work across specialties and levels. Involving multidisciplinary team, including senior physicians, is quite important developing ownership of the project and sustaining improvement.
- Small changes make a big difference. We can significantly improve our performance by brainstorming root causes and redesigning our current working system without significant additional resource requirements. It is quite important, especially in resource-constrained countries like ours.
Feasible and sustainable interventions such as user-friendly triage papers and training has increased our ability to successfully triage and classify patients. In addition, introducing a scope-based practice that uses clinical guideline in the emergency room has successfully improved the pediatric emergency service quality score. These interventions have also impacted subsequent patient satisfaction in a positive way.
Dawit Yifru, MD is Director of Quality and Clinical Governance Directorate at St. Peter’s TB Specialized Hospital and an IHI Improvement Advisor.