Improve discharge safety with a checklist

Discharging a child from the emergency department can be a complex process and having a standardized discharge process can prevent harm to the child. A sentinel event at Boston’s Children Hospital in Massachusetts prompted a team at the hospital to create a quality improvement program with the goal eliminating serious preventable adverse events linked to discharge by February 2019. At the virtual 2021 Pediatric Academic Societies meeting, Niloufar Paydar-Darian, MD, attending physician at Boston Children’s Hospital, presented the results of the program.

The improvement program occurred at Boston Children’s Hospital, a 400-bed academic children’s hospital that has approximately 60,000 emergency department visits every year, which results in 80% of emergency department patients being discharged. The team used data from the data warehouse, safety event reporting system, and Press Ganey patient survey results. The program had 4 key drivers:

• Ensure that parents felt equipped to provide care for the child at home
• Promote communication between care team members
• Completely reconcile all components or testing and treatment
• Foster awareness of the value of high-quality discharge to the outpatient setting

To help parents be prepared to care for their child, the program created a “5 things to know before you go” handout that had 5 questions that parents should have the answer to: (1) what is the diagnosis; (2) what medications or treatments does the child need; (3) who should the child receive follow-up care from and when should this occur; (4) what reasons may require the child return to the emergency department; and (5) does the parent have any other questions. For fostering awareness, the program emailed out data and success stories from the program twice during the program as well as an initial marketing push.

To assist with care team communication, the program created a discharge checklist that was nicknamed ‘the golden ticket’ and has 3 sections: a doctor to-do list, a nurse to-do list, and a huddle meeting between doctor and nurse. The doctor to-do list includes writing any prescriptions, reviewing the discharge plan with the patient and the family, and printing discharge instructions. The nurse to-do includes removing medical equipment, asking if the patient or family has any questions, and reviewing medication administration. During the huddle, both should check for outstanding orders and vital signs within an hour of discharge and ensure that the patient name matches all instructions and prescriptions.

Over the course of the program, the discharge checklist was completed roughly 87% of the time, with initiation of the marketing and data sharing leading to spikes in completion. Before the program, the vital signs were assessed within 60 minutes of discharge 61% of the time. After the initiative, they were assessed 83% of the time. Although there was no change in how parents perceived discharge information as well as length of stay or 72 hour return visits to the emergency department, there have been no serious preventable safety events since April 2018.

Reference

1. Paydar-Darian N. Improving discharge safety in a pediatric emergency department. Pediatric Academic Societies Meeting 2021; May 4, 2021; virtual. Accessed May 4, 2021.