P2D184: Bettering Broken Bones: Decreasing Emergency Department Length-of-stay for Sedated Orthopedic Care

Purpose/Objectives: Patient flow or length-of-stay is a primary driver of the quality of care we provide for all patients in the emergency department (ED). Children undergoing procedural sedation for orthopedic fracture reductions experience unnecessarily longer lengths of stay (LOS) in the ED, compared to other patient populations. Sedated orthopedic reductions require the coordination of multispecialty and multidisciplinary staff. This type of coordination is particularly challenging in an environment with other competing emergent needs. We hypothesize that improving efficiency and standardizing practice of care in this patient population will lead to improved satisfaction for patients, families, and staff. Our goal was to improve overall ED efficiency and patient experience in 6 months by reducing the mean LOS from 6.6 hours to 5.5 hours for children with upper extremity fractures requiring sedation for fracture reduction.

Design/Methods: A multidisciplinary team was assembled representing pediatric emergency medicine, orthopedics, radiology, emergency nursing, and radiology technologists. The project scope focused on measuring process steps for pediatric patients undergoing ketamine sedation for fracture reduction. Process observation and value stream mapping (VSM) informed opportunities to reduce waste. Occurrences of waste were centered around a few major themes including communication, prioritization, and coordination of the many steps in the sedation process. Chart review and Pareto analysis identified that 80% of delays were associated with pre-and post-reduction x-rays. A key driver diagram was developed to organize our theory for reducing the mean length-of-stay from 6.6 hours to 5.5 hours in 6 months. The pareto analysis indicated that targeting the post-reduction x-ray interval would result in the highest yield; thus, we reorganized the post-reduction x-ray process to capitalize on value-added process steps. Using PDSA cycles, we refined the process change and measured sustainable outcomes.

Results: Improvement measures and VSM times were tracked for pediatric orthopedic sedations using statistical process control charts (X-charts). Special cause variation was observed after testing and implementing the new post-reduction process. The average post-reduction x-ray interval was reduced by half, from 66 minutes to 33 minutes. The average total ED LOS was reduced to 5.6 hours, and we achieved unprecedently efficient throughput for some patients.

Conclusion/Discussion: Reducing mean ED LOS in pediatric populations is possible with an interdisciplinary team, solid outcome measures, and quality improvement tools. Understanding the problem and system is key to improvement. This means looking for variation and waste in the system. Going to the gemba, the actual place where process steps occur, will reveal variation, waste, and solutions. Next steps include ensuring spread of key process improvements to all emergency department patients requiring sedated orthopedic reductions and reducing waste in the pre-sedation aspects of the care process.