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Objectives: Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMARTAIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period. Methods:The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED. Results:The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients.Conclusions: This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.

A 10-month-old, unimmunized male with history of complex febrile seizure presented to the pediatric emergency department for fever and progressing rash. His mother described an erythematous, urticarial rash starting on his chest 4 days prior to presentation and spreading to involve his back, face, and extremities. At onset of rash, he developed persistent fevers to a maximum of 40.5°C, cough, and increasing fussiness. Parents denied recent travel, known sick contacts, daycare attendance, neck stiffness, eye redness, vomiting, diarrhea, rhinorrhea, or obvious oral lesions.Fifteen days prior to presentation, he was evaluated for complex febrile seizure. He presented to the emergency department with a generalized tonic-clonic seizure of 30-minute duration associated with a fever of 39.1°C. He received rectal lorazepam at presentation and a loading dose of intravenous phenobarbital with resolution of activity. Computed tomography scan of the head was normal. Lumbar puncture was declined by parents, but urine and blood cultures were negative. He was continued on maintenance dosing of phenobarbital during his hospitalization. He was discharged home with the presumptive diagnosis of complex febrile seizure secondary to viral illness and with instructions to continue phenobarbital at home.