Clinician documentation is highly variable, and awareness of documentation requirements remains low despite post-training experience. At our hospital, critical care (CC) documentation was inconsistent. Our aim was to increase appropriate CC attestations from 51% to 90% for status asthmaticus, anaphylaxis, and diabetic ketoacidosis in the pediatric emergency department by December 2021.


A physician team developed a key driver diagram. Retrospective baseline data using International Classification of Diseases, Ninth and Tenth Revision codes were obtained from January 2018 to September 2020, after which data were followed prospectively in consecutive groups of 20 encounters. Statistical process control charts were used to analyze data. Nelson rules were used to detect special cause variation. Primary outcome was the inclusion of appropriate CC attestations. Interventions included education, CC attestation templates, and provider feedback. We also tracked charges for the 3 diagnoses studied. Process measures included template use. Balancing measure was refusal of payment by insurers.


P-charts were used to analyze primary outcome and process measures. X-bar charts were used to analyze charges. Baseline data represented 706 encounters with 51% including CC documentation. Following clinician education and release of the CC template, special cause variation was detected, and centerline shifted to 88.1% (Fig 2). Average charges per encounter increased from $4527 to $5385. There was no reported refusal of payment.


We successfully achieved improvements in CC documentation in the 3 diagnoses of interest through education and process changes in documentation, leading over $1 million in new charges over the past 15 months.

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