From Doorknob Phenomenon to Anticipated Event: Discharge Vital Signs in the Emergency
JohnMorrison, MD, PhD, Pediatric Hospitalist, Johns Hopkins All Children’s Hospital
How often do you obtain and review a fresh set of vital signs before discharging a
child from your emergency department (ED)? Or from your clinic or the hospital for
that matter? Given that discharge tachycardia alone can place a patient at higher
risk for return to the ED or admission to the hospital, you may want to consider checking
those vitals one last time.1,2 But how? In this month’s Pediatrics (10.1542/peds.2019-0436), Vukovic and colleagues share their efforts to ensure patients have vital sign measurements
prior to discharge from the ED in an effort to safely transition children home.
The quality improvement team set out to increase the percentage of pediatric patients
discharged with a complete set of vital signs from 22% to 95% at a university-affiliated,
tertiary-care pediatric ED. Children with an Emergency Severity Index (ESI) of 1,
2, or 3 (indicating higher-risk for severe illness) or children with abnormal presenting
vital signs regardless of ESI were the focus of the QI efforts. An interprofessional
team of nurses, paramedics, and attending physicians identified three key drivers
that would lead to successful achievement of their goal: standardization of age-based
abnormal vital signs, standardizing the process for when to obtain discharge vital
signs, and providing guidance to reduce the risk of readmission or representation
to the ED after discharge. Vukovic et. al. incorporated multiple interventions targeting
these key drivers including instituting departmental policy requiring discharge vital
signs for eligible patients, provider education, informational cards highlighting
age-based abnormal vital signs, and best practice alerts (BPAs) for both providers
and nurses. The QI team utilized continuous improvement cycles with interval assessments
of the primary outcome. Secondary measures included the frequency of return to the
ED within 72-hours and hospital admissions. Success of the intervention was balanced
with mean length of stay (LOS) in the ED, where a longer LOS may indicate unanticipated
burden to the ED workflow or providers delaying discharge for ongoing vital sign abnormalities.
Over 7,000 ED patients were assessed during the interventional period from September
2017 – January 2019. The QI team successfully increased the percentage of eligible
patients with discharge vital signs from a baseline of 21.5% to nearly 85%, an improvement
that was sustained for a period of at least seven months once the initiative concluded.
As with many QI efforts, the successes were incremental, with each cycle of improvement
addressing a different barrier to success. An initial increase from baseline to just
over 40% of patients receiving discharge vital signs was obtained with implementation
of a paper-based discharge vital signs form, highlighting that even low-tech interventions
can be impactful. Through careful study of initial interventional cycles, Vukovic
and colleagues learned that it was difficult for nurses and providers to routinely
identify which patients necessitated discharge vital signs among the hustle and bustle
of a busy pediatric ED. The vital sign policy was accordingly updated to include
all “core” rooms in the ED, which routinely housed patients already meeting inclusion
criteria for receiving discharge vital signs. This seemingly simple but important
change improved the success rate from approximately 50% to nearly 80%. Only a modest
improvement to the final rate of ~85% came with initiation of the EMR-based BPAs.
Although the QI team ultimately did not meet their goal of 95% of eligible patients
receiving discharge vital signs, an overall improvement by over 60% from baseline
is far from failure. And, the team was able to reach this level of success without
prolonging a patient’s LOS while in the ED. It should be noted that, although the
intervention was predicated on the premise that reviewing discharge vital signs could
ultimately reduce 72-hour ED re-visits, the QI team did not show any significant change
in this metric during the study period. This is likely multifactorial, and our ability
to learn from this observation is further limited by no mention on what proportion
of patients re-presenting for care were originally discharged with abnormal vital
signs (which could suggest a potential targetable intervention). Finally, as with
all QI initiatives, the generalizability of this single center’s success to a community
setting with or without pediatric-trained providers is unknown. However, the significant
improvements seen with low-tech paper-based intervention and the cohorting of at-risk
patient groups suggest such settings could feasibly implement these changes if desired.
See the results for yourself and see which interventions by Vukovic et. al. could
work for your institution in this month’s Pediatrics!
Wilson PM, Florin TA, Huang G, Fenchel M, Mittiga MR. Is Tachycardia at Discharge
From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort
Study. Ann Emerg Med. 2017;70(3):268-276 e262.
Scott HF, Deakyne Sj, Woods JM, Bajaj L. The prevalence and diagnostic utility of
systemic inflammatory respons syndrome vital signs in a pediatric emergency department.
Acad Emerg Med. 2015;22(4):381-389.