As a resident and now a critical care fellow, boarding times in the emergency department (ED) are an indelible part of my life. Be it waiting until the patient has been put into the room and vital signs obtained, waiting for the beds to open up, waiting to hear back from the admitting team, waiting for a laboratory test result–the series of steps that need to occur may make it seem that the stars need to align just right! Having been on both sides of the opening sentence, “I have a patient in the ED in bed 4…”, (as a former resident working in the ED or now hearing about a patient from the ED as a fellow), I was thrilled to read the Quality Report by Kouo et al (10.1542/peds.2019-1477) that described how a quality improvement project, led by residents, made such a difference in patient care and workflow in the ED.
Realizing that waiting times in their hospital’s ED were longer than the national average, the authors of this Quality Report keenly dissected the current processes and discussed possible steps to help enhance it. They chose the pediatric hospital medicine service, a traditionally resident-led service in academic children’s hospitals and aimed to decrease ED boarding time by 10% in 6 months. Based on staff interviews and process examination, the requirement for the admitting resident to go to the ED to examine a patient before accepting them was a rate-limiting step. To address this issue, the authors came up with a series of excellent and practical interventions: mobile phone app-based pages to convey acceptance of the patient, visual and educational reminders about the importance of remembering to send acceptance pages, and encouraging accepting stable patients to move from the ED to the inpatient unit accepting that patient prior to the complete history and physical examination. With these interventions, the team working on this project was able to maintain a sustained decrease in boarding times for over 3 years after their intervention. As a balancing measure, they tracked patients being transferred to the pediatric ICU within 12 hours after admission to account for any possibly rushed admission that may have needed to be admitted to the ICU in the first place. There was no significant change in the number of ICU transfers which is reassuring. It also perhaps is a reminder that the practitioners in the pediatric ED in academic centers are often residents or faculty from the same hospital who are familiar with the system and floor capabilities; they likely have a good pulse on what patients may be appropriate for the floor or may need to be watched for clinical decompensation.
The authors note that the decrease in boarding times had started before the initiation of the study, likely due to a combination of better patient allotment (alternating teams) and reduced team burden (not covering neurology and several surgical services). However even with these changes, the boarding times would be expected to trend up with higher patient volumes seen in the winter months and they did not. The study interventions helped prevent that volume-associated increase and were likely important in maintaining the efficiency of the ED disposition process in the busier months. This study is a commendable reminder of how residents can lead the way to change, including changes in culture, which may be considered difficult to implement by a group of young people rotating through services for three years. It also wonderfully demonstrates the challenge of seemingly logical changes that increase efficiency, as introducing them requires a lot of work and iterative improvements in process before gaining acceptance and achieving better outcomes. The residents leading this study inspire others by this excellent example of quality improvement that they spearheaded despite their still being in training.