Pediatric Emergency Department Burn Discharge and Clinic Readiness: A Quality Improvement Project

Abstract

Introduction: The shift to outpatient care for pediatric burn injuries has placed a greater responsibility on caregivers for wound care and follow-up planning. Nonadherence to burn care and follow-up appointments can lead to negative emotional and physical health outcomes. Both parental education and pain control with dressing changes are important factors for adherence to outpatient care. This single-center quality improvement project aimed to improve pediatric burn patients discharged from the emergency department with the correct instruction packet and the percentage of qualifying patients prescribed oxycodone for premedication for their initial clinic appointment.

Methods: A multidisciplinary team retrospectively examined barriers using a fishbone diagram, developed a key driver diagram, and designed interventions, including updated custom instructions, printed discharge pamphlets, electronic medical record changes, enhanced e-prescribing access, linked International Classification of Diseases, Tenth Revision codes, targeted provider feedback, and education sessions. We tracked monthly data using statistical process control charts.

Results: At baseline, 46% of patients received the correct discharge packet; following interventions, we observed a centerline shift to 78% with sustained improvement. Seventy percent of qualifying patients received an oxycodone prescription for premedication before clinic follow-up at baseline, and we saw a sustained baseline shift to 93% after interventions.

Conclusions: Following multiple targeted interventions, there was a sustained improvement in the use of a custom burn discharge instruction packet and oxycodone prescriptions. Future research should examine the impact of discharge instructions and oxycodone prescriptions on the timeliness of outpatient appointment scheduling and pain scores.

Fig. 1.

Fishbone diagram created by our multidisciplinary team to show possible root causes and areas of challenge regarding the discharge process, including selection of the correct instructions and discharge prescriptions.

Fig. 2.

Key driver diagrams of burn discharge initiatives in the ED, including all pertinent interventions to discharge instructions (A) and discharge prescriptions (B).

Fig. 3.

Statistical process control chart (p-chart) demonstrating monthly percentages of discharged pediatric ED patients receiving a custom burn instruction packet. EHR, electronic health record; LCL, lower control limit; UCL, upper control limit.

Fig. 4.

Statistical process control chart (p-chart) demonstrating monthly percentages of qualifying patients receiving a prescription for a 1-time dose of oxycodone. CL, centerline; EHR, electronic health record; UCL, upper control limit.

Fig. 5.

Statistical process chart (t-chart) demonstrating the days between errors in the dosing of discharge oxycodone prescriptions.

Fig. 6.

Statistical process chart (p-chart) demonstrating the monthly percentage of unscheduled returns for patients with burn injuries who are discharged from the pediatric ED. CL, centerline; UCL, upper control limi.