Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illnesshnjury in an ED.Methods: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of deiay. In Phase I, two solutions were implemented. In this Phase I1 of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase I1 intervention 48-hour periods and one post-Phase I1 intervention 48-hour period were analyzed.Results: Before the Phase I changes, the mean 2 SD LOS was 92 2 46 min. After the Phase I changes, the LOS was 67 2 31 min. After the Phase 11 changes, this was reduced to 57 2 34 min (p c 0.05). Conclusion:The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients. I Care of the so-called "nonurgent" patient remains controversial in the emergency medicine literature. While some would argue that these patients can be cared for outside the ED,'-3 others state that such patients require the "safety net" of the ED'-* to ensure receipt of timely and appropriate quality care.Quality has been defined as "meeting the customer's requirements."' To meet the customers' requirements, each institution must define the community it serves and, by extension, its customers. At St. Paul's Hospital in Vancouver, for example, a community stakeholders' meeting demonstrated that our customers included a large variety of ambulatory patients, many of whom have substance abuse and psychiatric problems. These ambulatory patients are often treated in the fast-track (FT) area of an ED. In general, FT patients present with nonurgent complaints, yet they cannot be triaged away from the ED. They often present during off-hours when no other service is available, and they may be unable or unwilling to go elsewhere in the daytime for alternative care. This population also includes a significant subset of potentially violent and often disruptive patients.While meeting the needs of such challenging patients, we cannot ignore the needs of other community members, including our pediatric population, the elderly, and the disabled. We sought to improve the quality of care to this diverse group of patients. Due to previous failures to meet this objective, our ED committed to a continuous quality improvement (CQI) process for redesign of our triage and FT areas. In a previous paper," we demonstrated how implementation of Phase I of the
Introduction Pediatric burn care presents two unique population subsets that require distinctive care from adult and non-burn patients, respectively. While prior research has led to the creation of best practices for burned adults and non-burn pediatric patients, the standard of care regarding long-term pediatric burn intubation varies widely and deviates from accepted standards in the non-burn pediatric world. In this retrospective review, we analyze one burn center’s experience managing ventilation and extubation of pediatric patients. Methods We reviewed all pediatric patients admitted to the burn and wound care ICU who were intubated for more than 24 hours. Patient data was collected from 2012 through 2022. 442 patients were initially identified and 142 remained after removing screen failures. We analyzed 3 groups which included total burn surface area (TBSA), inhalation injury, and time on the ventilator. Results The first group broken down by TBSA yielded the most significant results in our 7 of 10 metrics. All significant metrics including mortality, length of stay (LOS), and pulmonary hypertension (HTN) were directly correlated to burn TBSA. Patients with higher TBSA were also significantly more likely to require reintubation after coming off the ventilator. Inhalation injury presented on admission was also a significant indicator for developing acute respiratory distress syndrome (ARDS). Patients who remained on the ventilator for >7 days were significantly more likely to develop pulmonary HTN, however mortality and reintubation rates notably did not increase in this group. Conclusions There is much debate in the burn world as to whether standard practices should carry over from other specialties when treating severely burned patients. Much of our data confirms, in pediatric patients, findings of adult patients found in the literature. Mortality, LOS, and time on the ventilator expectedly increased with burn TBSA. Inhalation injury was a significant indicator for ARDS which implies that proper screening for this type of injury is a key to predicting long-term treatment. What is perhaps most notable in this data is the fact that, unlike in the adult burn population, there was no significant difference in mortality between short and long-term intubations. Additionally, patients who required reintubation (n=7) were significantly more likely to have a TBSA >40%, but those who remained on the ventilator >7 days were not more likely to require intubation after extubation. This implies that patients should be left on the ventilator, if necessary, without resorting to aggressive challenge breathing trials for early extubation as is common in adult population. With this data we will also identify our rare cases of pediatric tracheostomy placement and indications for its use. Applicability of Research to Practice This projects shows how intubation of pediatric burn patients can be maintained safely and effectively in the critical care setting.
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