Pediatric emergency care process

In the previous study of existing ED quality measurements (Alessandrini et al.

2011), most of the measurements (67%) were categorized as process

measurements. The most commonly measured PED process indicators included the rate of LBTC patients and patients’ ED LOS (Alessasandrini et al. 2011).

Another process measurement that recent studies have used is the rate of return visits (RVs) to the ED (i.e. Augustine et al. 2018; Truong et al. 2017). In these quantitative studies, the process measurements have been treated as independent indicators of care quality or care efficiency, and the aim has been to find the explanatory factors for LOS in the patients’ related factors. Table 2 shows the characteristics of studies concerning the pediatric care process.

Pediatric patients’ emergency department length of stay

ED LOS is a routinely used measurement, which has been used to measure ED process efficiency. LOS, usually time in minutes, is measured from ED arrival at

that ED LOS should be under 240 minutes, and any time over this period is considered prolonged ED LOS (Hofer et al. 2017). ED LOS of over 4 hours among pediatric patients has been found to be related to hospital admissions, the morning hour of attendance, and attendance in wintertime (Bekmezian et al. 2011). Also, prolonged LOS is related to pediatric patients with physician referrals, morning admissions, and gastrointestinal infections. Pediatric patients’

shorter ED LOS was related to their low-acuity triage level and having an upper respiratory infection. (Hofer et al. 2017.)

Patients who left before treatment completion

One measurement of the pediatric emergency care process is the rate of LBTC patients. That term describes all those emergency patients who exit the ED before receiving all elements of the care process (Alessandrini et al. 2011). The term LBTC was used in this study when describing patients whose care was not finished. The literature has also used the concept “left without being seen”

(LWBS), which has been used when describing the number of patients who leave the ED before examination by a physician or other medical professional, and the definition of the term varies by site (Doan et al. 2014; Gaucher et al.

2011).

The number of patients with LBTC proportions among low-acuity patient (CTAS levels 3–5) groups has progressively increased from 2% to as high as 7%, from 2002 to 2011, respectively (Doan et al. 2014). Factors that have been found to be related to pediatric patients leaving the ED without receiving care included a low-acuity triage class (CTAS levels 4–5), evening arrival to the ED, and attending with self-referral (Gaucher et al. 2011).

Pediatric patients’ return visits to emergency departments ED return visits (RVs) are used as ED process measurement. Usually, the number of RVs is measured either 72 hours from discharge (i.e. Augustine et al.

2018) or 7 days after ED discharge (Truong et al. 2017). When using the RV rate of one area, nearly 9% of all pediatric visits in Canadian hospitals were RVs over the course of a week (Truong et al. 2017). Parents/caretakers return to the ED because their child’s symptoms continue to worsen and they lack the knowledge to help him/her at home. In the parents’ opinion, during the first visit to the ED, more tests, treatments, medications, and information should be provided (Augustine et al. 2018).

Giving and receiving care information seem to be important factors influencing ED RVs. A previous study (Gallagher et al. 2013) focused on pediatric patients

and their families who had limited English proficiency (LEP) and a higher risk for ED RVs than the English-speaking population (Gallagher et al. 2013). Hospitals with the highest RV rates were those whose population had lower household incomes and more likely governance insurance, as well as those with less staff specialized in pediatric medicine (Pittsenbarger et al. 2017). In the previous study (Alessandrini et al. 2011) of existing ED quality measurements, most of the measurements (67%) were categorized to be process measurements. The most commonly measured PED process indicators included the rate of patients who left without treatment completion (LBTC), patients’ ED length of stay (LOS). (Alessasandrini et al. 2011.) Another process measurement that is used in recent studies is the rate of return visits to ED (i.e. Augustine et al. 2018;

Truong et al. 2017). In these quantitative studies the process measurements have been treated as independent indicators of care quality or care efficiency and the aim has been to find the explanatory factors for LOS in the patients' related factors. Table 2. shows the characteristics of studies concerning the pediatric care process.

Table 2. Summary of studies according to pediatric emergency care process (n=9)

Author, year Purpose Methods Results

Alessandrini et

A total of 405 performance measurements were found.

From IOM (2007) quality standards, most of the measures were related to ED effectiveness.

According to Donabedian’s quality model, 67% of measures were linked to the care process, 29% to the outcome, and 4% to

The main reasons for returning to the ED were a child’s symptoms continuing (92%) or

getting worse (70%), lack of parents’ knowledge with helping

methods at home, or not understanding their child’s illness

(569%). Parents thought that a larger number of tests (55%) and treatments (45%) should be done to the child at first ED visit,

and they also supported

medication (41%) and giving

Prolonged ED-LOS was found more frequently for admitted pediatric patients and

was associated with Hispanic ethnicity, ED visit during the winter season, and patients’

early morning arrival.

Patient volumes increased by 30% within the 10-year study period. The hospitalization rate remained at approximately 10%.

Increased LWBS proportions among low-acuity triage levels of 2% to near 7% (CTAS3–CTAS5).

Patients’ ED LOS at all triage levels was increased during the

study period.

11.7 % of patients were with LEP. Out of English-speaking patients, the rate of RVs was 1.2%, and for patients with LEP,

it was 1.6%. Patients with LEP had a higher risk of ED were low-acuity triage class

(CTAS levels 4–5), evening arrival to ED, attendance with

self-referral, age between 3 months and 11 years, and living

near the hospital.

Prolonged LOS was related to physician referral, morning admission, and gastrointestinal

infections. Inversely related to LOS were triage level 5 and upper respiratory infections.

patients’ ED

Served populations of hospitals with the highest RV rate had lower household incomes, and

the hospitals had greater likelihood of governance insurance and lower pediatric

medicine specialist staffing. visits, nearly 9% of all visits were linked to RVs. RVs in PEDs

comprised 22% and those in general EDs 78%.