Abstract
Introduction:
Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed.
Methods:
Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period.
Results:
One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period.
Conclusion:
The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.
Keywords: plastic surgery, consult, emergency department, sedation
Abstract
Introduction:
Les services de consultation ont une influence sur le cheminement à l’urgence. Une durée de séjour prolongée à l’urgence est corrélée avec le surpeuplement de l’urgence et, par conséquent, une diminution de la qualité des soins et de la satisfaction des équipes de professionnels de la santé. Pour améliorer la prise en charge des patients à l’urgence pédiatrique qui ont besoin de compétences en chirurgie plastique et reconstructive (CPR), les chercheurs ont analysé les processus actuels.
Méthodologie:
Les chercheurs ont colligé les caractéristiques des patients et les mesures des consultations en CPR dans une urgence pédiatrique sur une période de trois mois. Ils ont suivi l’analyse des données d’une intervention de rétroaction au personnel de l’urgence et de la CPR. Par la suite, ils ont repris la collecte de données pendant trois mois et l’ont comparée à la période précédant l’intervention.
Résultats:
Les chercheurs ont examiné 198 consultations en CPR, chez des patients d’un âge moyen de 6,3 ans. Les diagnostics les plus courants (52 %) étaient les brûlures et les traumatismes de la main. Les chercheurs ont considéré 81 % des orientations en CPR comme appropriées. Ils ont constaté que 25 % des consultations en CPR ont été demandées après les heures de travail, sans que les caractéristiques de patients soient différentes de celles demandées pendant les heures normales. Ils ont remarqué que 60 % des consultations étaient liées à des interventions à l’urgence. Ils ont déterminé que le délai entre l’inscription à l’urgence et la demande de consultation en CPR (116,5 minutes), la qualité de la sédation lors de l’intervention (52 % étaient classées comme inappropriées) et la durée globale du séjour à l’urgence (289,2 minutes) étaient les points les plus préoccupants et ont été abordés lors de l’intervention de rétroaction. La durée du séjour à l’urgence et la qualité de la sédation ne se sont pas améliorées après l’intervention.
Conclusion:
L’étude fournit des points de vue détaillés des caractéristiques de la consultation en CPR au sein de la population à l’urgence pédiatrique. Malgré le taux élevé d’orientations appropriées et l’intervention de rétroaction, les chercheurs ont constaté d’importantes inefficacités qui justifient plus d’efforts de collaboration pour optimiser la qualité des soins auprès des patients à l’urgence pédiatrique et pour accroître la satisfaction des professionnels de la santé en cause.
Introduction
Plastic and reconstructive surgery (PRS) is a frequently requested consult services in tertiary care adult and paediatric emergency departments (EDs). 1,2 The nature and commonality of emergency cases within the scope of PRS requires 24-hour access to a PRS specialist to the ED every day. Therefore, in most institutions, PRS consultations are provided by an in-house or on-call PRS trainee and an on-call board certified plastic surgeon. Most commonly, PRS specialists are requested for consultations on burns, upper extremity injuries, and facial trauma. 3
Over the last decade, patient census of most adult and paediatric EDs has significantly increased not only in North America but globally. 4 -9 The phenomenon of ED overcrowding has been described and analysed frequently in the literature and has proven to impact quality of patient care as well as job dissatisfaction among medical professionals. It has been shown that ED length of stay (LOS) increases with ED overcrowding. 6,10,11
Within this context, there are 3 main areas of concern: First is the appropriateness of specialty referrals in the ED. Urso-Baiarda 2 investigated the referral appropriateness to the Plastic Surgery department at Leeds General Infirmary, United Kingdom, and found that 68% of referrals from ED were deemed appropriate defined as a patient requiring hospital admission, surgical intervention, or review by a senior PRS staff member. Inappropriate referrals were more likely to occur during staff changeover at 1 to 2 am or at 10 am to 12 pm which was at the period of highest volume in the ED. This study illustrated the importance of evaluating both the appropriateness of referrals as well as the impact of the time of day which the patient is referred.
Second, the negative effects of specialty consultations on the efficiencies of care management and LOS in the ED are a concern. In 2014, Brick et al 12 published their results of a cohort study based on 2 tertiary care hospitals in Alberta, Canada. They found that 54% of total ED LOS (ie, time between arrival in ED to time of discharge or admission to inpatient unit) was attributed to the time interval between specialty consultation request and disposition decision in patients who were discharged home. In admitted patients, the consult time was reduced to 33% of the total ED LOS. Improving the efficiencies in the referral process to PRS and carrying out the recommended treatment will have a positive effect on overall ED LOS and patient experience.
Third, PRS consultations are found to be frequently requested after hours 1 resulting in an increased after hour work load on PRS trainees. At the same time, current labour regulations require the trainees to rest following busy calls and thus after hour consultations directly impact on educational exposure of the PRS trainee the following day.
In 2012, to improve the efficiency and management of PRS cases referred from ED, the Division of PRS at the Hospital for Sick Children (SickKids) implemented a daily PRS Emergency Clinic, Monday to Friday, between 8 and 9 am to manage non-urgent, but necessary referrals from the ED. The idea was to eliminate unnecessary after hour ED consults to shorten the patient’s ED LOS and at the same time decrease the work load of the PRS trainees in the late evening and overnight. However, while this new initiative was well received and utilized by ED staff, PRS staff and trainees continued to feel that a large number of requested consultations from the ED remain inappropriate or untimely (eg, after a prolonged wait time in the ED). Inefficiencies due to logistics and available resources (eg, staffing, treatment space) for patients requiring interventions were also a concern. These circumstances were identified as risk factors associated with decreased quality of patient care as well as decreased patient, family, and inter-professional satisfaction with health care. Lastly, the negative impact on educational opportunities of PRS in-house staff on the following day post-call was a continued ongoing concern. Therefore, the purpose of this study was to conduct a quality improvement (QI) initiative to evaluate the characteristics, logistics, and timing of ED referrals to PRS before and after an education feedback intervention to the ED regarding the strengths of current processes and areas of improvement. The aim was to improve management of paediatric ED patients requiring PRS expertise with respect to patient care as well as ED and PRS unit efficiencies.
Material and Methods
A QI study using the Plan-Do-Study-Act Model was implemented to tabulate and document metrics of all PRS consultations in the ED at The Hospital for Sick Children before and after the ED education feedback intervention. All PRS trainees on call prospectively collected data during two 3-month data collection periods: Pre-intervention, August 1 to October 31, 2016; and Post-intervention, October 1 to December 31, 2017. Emergency department staff was unaware of this study at the time of the pre-intervention data collection period.
The feedback education intervention took place in August 2017 which included separate in-house presentations to both ED and PRS departments about findings of the pre-intervention analysis, followed by discussion regarding issues pertaining to the appropriateness of referrals to PRS, wait times, and optimization of management of cases requiring sedation. For those who could not attend the feedback education session, a summary of the key findings from the pre-intervention period was circulated electronically to the ED staff through their monthly (September 2017) departmental newsletter. After this intervention, data collection resumed in the same manner as the pre-intervention data collection period.
On the day of consultation, each trainee collected data on patient demographics, timing appropriateness of referral, reason for consultation, intervention(s) provided, and sedation management on a predetermined data collection form. Categorical data (eg, diagnosis, type of intervention) were classified into predetermined nominal scales. Trainees were encouraged to provide free-text responses when data did not fit the predetermined categories or to justify their rationale for their response (eg, presence or absence of communication issues). The quality of sedation was rated by PRS trainees on an ordinal rating scale from 1 to 10. Sedations rated 9 to 10 were deemed adequate as the trainee was able to perform the intervention without difficulties, 5 -8 inadequate with some or significant difficulties and 1 -4 as inadequate with major difficulties. The term “difficulties” would refer to the level of safety, pain, and restlessness during the procedure as well as overall efficacy. Retrospective review of the medical records of all cases was conducted at the end of the data collection periods to verify and complete the data sets.
Data analysis was conducted using IBM SPSS version 25. Descriptive statistics were used to describe the nature and timing of PRS referrals. Chi Square Analysis and Mann-Whitney U tests were used to compare categorical and continuous data respectively of pre- and post-intervention data collection periods, as well as the referrals made during regular versus after hours. The 24-hour period was subdivided into regular hours (7:00 am to 10:30 pm) and after hours (10:31 pm to 6:59 am).
Results
General Characteristics of PRS Consults
One hundred ninety-eight PRS consultations were documented and reviewed: 107 pre-intervention and 91 post-intervention. Mean patient age was 6.3 ± 4.9 (range: 0.5-20.4 years), and 79 patients were female (40%) while 119 were male (60%). Seventy-eight percent (n = 155) of the referrals were from patients who lived within the greater Toronto area (GTA). In one-third (n = 67) of the referrals, the PRS trainee on-call was pre-consulted before the patient’s arrival in the ED. Burns and hand trauma accounted for half (n = 52%) of consultations, followed by lacerations and facial trauma (Table 1). Gender, referral location (ie, GTA or outside), and PRS pre-consultation were not statistical different between the referrals in the pre- and post-intervention periods (Table 1). However, the patients in the post-intervention group were significantly younger (Mann-Whitney U, z = −2.7, P = .006) and there were a greater proportion of children with burns in this time period (χ 2 = 12.6, P = .05).
Table 1.
Characteristics of PRS Consults.
| Full cohort (n = 198) | Pre-intervention (n = 107) | Post-intervention (n = 91) | |
|---|---|---|---|
| Age | 6.3 ± 4.9 | 7.1 ± 4.9 | 5.3 ± 4.7 |
| Gender, M/F | 119/79 | 58/49 | 61/30 |
| Outside GTA referralsa | 33 (17%) | 22 (21%) | 11 (12%) |
| Diagnosis | |||
| Burn | 57 (29%) | 23 (22%) | 34 (37%) |
| Hand trauma | 35 (18%) | 24 (22%) | 11 (12%) |
| Nail bed injury | 10 (5%) | 4 (4%) | 6 (7%) |
| Facial trauma | 24 (12%) | 17 (16%) | 7 (8%) |
| Laceration | 32 (16%) | 15 (14%) | 17 (19%) |
| Post-op complication | 13 (7%) | 9 (8%) | 4 (4%) |
| Other (eg, complex wounds) | 27 (14%) | 15 (14%) | 12 (13%) |
| PRS consultation appropriateb | 171 (86%) | 95 (89%) | 76 (84%) |
| PRS pre-consultedc | 67 (34%) | 35 (33%) | 32 (36%) |
Abbreviations: GTA, greater Toronto area; PRS, plastic and reconstructive surgery.
a Missing data on 10 patients.
b Missing data on 9 patients.
c Missing data on 3 patients.
Referral Appropriateness
All consultations were found to be linked to diagnoses within the scope of PRS practice. However, PRS trainees rated 9% (n = 18) of all requested consultations in the ED as inappropriate because they were considered either non-urgent or evaluated as cases that should be independently managed by a fully trained paediatric ED physician. After the intervention, the number of inappropriate referrals increased from 6% (n = 6) to 13% (n = 12), but was not statistically significant (χ 2 = 3.2, P = .07). Sixty-six of 198 (34%) patients seen in ED were admitted to the hospital and 118 (60%) were discharged home with a scheduled for follow-up in the PRS emergency clinic.
Timing of PRS Consults
Overall, 25% (n = 50) of the referrals (n = 197, missing data on 1 patient) were made after hours, between 10:31 pm and 6:59 am (Figure 1). A greater proportion of the patients who came after hours were from outside the GTA (χ 2 = 4.7, P = .03). Physician pre-consultation with the PRS trainee on-call prior to arrival to the ED was also more likely in the after hour patients (χ 2 = 25.5, P < .001). However, the after hour PRS consultations were on average, longer in duration 77.1 ± 60 minutes (range: 5-285) than during the regular hours, but this was not statistically significant (Mann-Whitney U, z = −1.3, P = .20). Lastly, there were higher proportion of patients who required intervention (66%) and sedation (52%) after hours compared to regular hours, but this was not statistically significant. Overall, the characteristics of regular and after hour PRS consultations was not statistically different between the pre- and post-intervention data collection periods (Table 2).
Figure 1.
Distribution of PRS consults over a 24-hour period (n = 193)*. PRS indicates plastic and reconstructive surgery.
Table 2.
Comparison of PRS Consultations During Regular Versus After Hours.
| Regular hours, 7:00 am to 10:30 pm (n = 147) | After hours, 10:31 pm to 6:59 am (n = 50) | |
|---|---|---|
| Outside GTA referralsa | 20 (14%) | 13 (26%) |
| PRS Consultation appropriateb | 130 (88%) | 40 (80%) |
| PRS Pre-consultedc | 36 (25%) | 31 (62%) |
| ED length of stayd | 283.6 ± 133.2 | 310.7 ± 163.7 |
| Duration of PRS consulte | 65.2 ± 51.9 | 77.1 ± 61.8 |
| Wait time between ED registration and PRS referrale | 119.5 ± 81.2 | 107.7 ± 110.4 |
| ED Intervention | 86 (59%) | 33 (66%) |
| Sedation requiredf | 62 (42%) | 27 (54%) |
| Sedation adequateg | 29 (47%) | 13 (50%) |
| Quality of sedationg | 7.68 ± 2.6 | 8.29 ± 1.9 |
Abbreviations: GTA, greater Toronto area; PRS, plastic and reconstructive surgery.
a Missing data on 10 patients.
b Missing data on 9 patients.
c Missing data on 3 patients.
d Missing data on 40 patients.
e Missing data on 6 patients.
f Missing data on 30 patients.
g Missing data on 8 patients.
Of the patients referred for PRS consultation, average ED LOS was 289.2 ± 139.8 minutes (range: 62-804, n = 191). The wait time between registration in ED and time of PRS consultation request was 116.5 ± 89.4 minutes (range: 0-521, n = 158), while the average duration of PRS consultation was 68.1 ± 54.6 minutes (range: 5-300, n = 192). The average length of PRS and ED LOS of patients who required treatment in the ED (72.0 ± 46.0, range: 5-210, n = 116) compared to those who did not require treatment (62.3 ± 65.5, range: 5-300, n = 76) was statistically significant (Mann-Whitney U, z = −5.5, P = .003). Emergency department LOS and the duration of PRS consultations were not significantly different at pre- versus post-intervention periods (Table 3). However, the average wait time between ED registration to PRS referral was significantly reduced to 81.8 ± 73.1 minutes (range: 0-435, n = 65, Mann-Whitney U, z = = −4.2, P < .001) in all (pre- and post-intervention) consultations when the PRS trainee was pre-consulted by the referring physician. Further, the overall ED LOS for these pre-consulted patients were significantly reduced to 243.9 ± 106.5 minutes (range: 64-499, Mann-Whitney U, z = −2.2, P = .03).
Table 3.
Length of Stay, Wait Time to PRS Referral, and Duration of PRS Consultation.
| Full cohort (n = 198) | Pre-intervention (n = 107) | Post-intervention (n = 91) | |
|---|---|---|---|
| Number of PRS consultation referrals during regular hours (7 am to 10:30 pm)a | 50 (25%) | 28 (26%) | 22 (24%) |
| ED length of stayb | 289.2 ± 139.8 | 290.6 ± 140.2 | 288.1 ± 140.3 |
| Duration of PRS consultation for all casesc | 68.1 ± 54.6 | 77.5 ±63.8 | 56.8 ± 38.1 |
| Wait time between ED registration and PRS referralb | 116.5 ± 89.4 | 116.6 ± 88.2 | ± 91.4 |
| Sedation cases only (n = 88) | |||
| ED length of stayb | 299.4 ± 123.1 | 330 ± 141.3 | 283.1 ± 110.5 |
| Duration of PRS consultation for cases requiring sedationd | 82.1 ± 46.3 | 95.2 ± 48.7 | 70.1 ± 41.0 |
| Wait time between ED registration and PRS referrale | 107.1 ± 79.3 | ± 89.6 | 104.1 ± 69.5 |
Abbreviations: ED, emergency department; PRS, plastic and reconstructive surgery.
a Missing data on 1 patient.
b Missing data on 7 patients.
c Missing data on 6 patients.
d Missing data on 2 patients.
e Missing data on 4 patients.
Characteristics of Consults Requiring Interventions
Sixty percent (n = 119) of the patients referred required a PRS intervention in the ED (Table 4). Burn debridement and laceration repair accounted for the largest proportion of PRS interventions provided in the ED, followed by complex wound care, nail bed revisions, and closed reduction of hand fractures (Table 4). Eighty-eight patients (44%) interventions required sedation. The duration of PRS consultations in patients who required sedation (mean ± standard deviation: 82.1 ± 46.3) were statistically higher than those who did not require sedation (50.5 ± 48.7), Mann-Whitney U, z = −5.5, P < . 001. Subsequently, patients requiring sedation were also younger (4.2 ± 3.7; Mann-Whitney U, z = −4.0, P < .001).
Table 4.
Plastic and Reconstructive Surgery (PRS) ED Interventions.
| Full cohort (n = 198) | Pre- intervention (n = 107) | Post- intervention (n = 91) | |
|---|---|---|---|
| ED intervention | 119 (60%) | 56 (52%) | 63 (69%) |
| Intervention | |||
| Burn debridement | 48 (40%) | 21 (28%) | 27 (43%) |
| Fracture reduction | 9 (8%) | 6 (11%) | 3 (5%) |
| Laceration repair | 29 (24%) | 12 (21%) | 17 (27%) |
| Nail bed revision | 10 (8%) | 4 (7%) | 6 (10%) |
| Complex wound care | 22 (19%) | 12 (21%) | 10 (16%) |
| Other | 1 (1%) | 1 (2%) | 0 (0%) |
| Sedation required | 88 (44%) | 41 (38%) | 47 (52%) |
| Type of sedationa | |||
| Intravenous (IV) | 60 (68%) | 30 (73%) | 30 (64%) |
| Nasal | 24 (27%) | 9 (22%) | 15 (32%) |
| Sedation adequatea | 42 (48%) | 16 (39%) | 26 (55%) |
| Quality of sedationb | 7.9 ± 2.4 | 7.1 ± 2.4 | 8.5 ± 2.2 |
a Missing data on 3 patients.
b Missing data on 8 patients.
Drugs used for sedation were mainly given intravenously (midazolam, ketamine, rarely propofol) in 60 patients (68%), and nasal (27%, fentanyl, midazolam) in 24 (27%). The quality of sedation was rated as inadequate in 52% (n = 38) of the 88 sedation cases. The average quality of sedation ratings was 7.9 ± 2.4 (range: 1-10). Most common problem was insufficient drug dosing that led to interruption of the procedure for re-dosing of drugs because the child was still too active and therefore impaired the surgical procedure. No serious adverse effects or complications of sedations were recorded. Eight (47%) of the documented communication concerns were related to arranging and carrying out patient treatment sedation. After the education feedback intervention, a statistically significant decrease in the duration of plastic surgery consultations of cases that required sedation was found (Mann-Whitney U, z = −2.8, P = .005, Table 3). Although the proportion of sedations that were deemed adequate remained unchanged (χ 2 = 3.1, P = .08), the quality of sedation rating was significantly lower in the post-intervention period (Mann-Whitney U, z = −3.0, P = .003, Table 4).
Discussion
The aim of this study was to improve management and patient care for PRS consultations in our paediatric ED by performing a pre- and post education feedback intervention analysis of PRS consults. This is the first study to give detailed insights in characteristics of PRS ED consults in the paediatric population. This data set identifies inefficiencies despite attempts to provide an education feedback intervention, and therefore calls for future collaborative efforts to strengthen efficacy and quality of care for paediatric PRS patients in the ED. The most pertinent issues are (1) triage efficiency/timing of consults, (2) referral appropriateness, and (3) quality of sedation for interventions.
Triage Efficiency and Timing of Consults
We identified burns, upper extremity trauma, and laceration to be the 3 main diagnose categories that account for almost 70% of consults in our analysis. This is consistent with a previous report from a PRS Department at a Tertiary Care Unit who evaluated referrals in an adolescent and adult population. 12 Exclusive data on children is not available. A common feature of these aforementioned diagnostic categories are that these conditions are easily identified as conditions within PRS scope of practice that require management. Further, most of these cases do not requiring extensive and time consuming diagnostic work-up. Despite the straightforward nature of these conditions, we found the average time from ED admission to referral to PRS be almost 2 hours in the analysed patient population. Mean duration of plastic surgery consultation in ED was 70 minutes. Gorman and colleagues 5 published slightly shorter average times to referral (58 minutes), but significantly longer PRS consultation times of 168 minutes in their single centre analysis in the United Kingdom. Overall ED LOS in our population was still over 4 hours suggesting unspecified inefficiency of ED work flow in the pre- and post PRS consult period rather than PRS consult service unavailability or inefficiency. Interestingly, our data clearly showed a significantly streamlined process with shorter time to referral, shorter PRS consultation time, and decreased overall ED LOS, when the referring physician directly contacted the PRS trainee before admission to the ED. These patients were labelled as “need for PRS consultation” at registration which would allow the patient to bypass or speed up the triage process and/or the initial medical assessment by ED staff. Unfortunately, the education feedback intervention did not improve the overall triage efficiency, timing of consults, and ED LOS for all consultations. As such, additional strategies to improve such processes is still needed. Successful decrease of ED LOS may directly increase patient satisfaction with received medical treatment, patient-oriented outcome, and decrease rates of complications and medical errors as shown in a decent number on publication on ED overcrowding. 7,13 -15 According to our findings, a practical solution to reduce ED LOS for our consults could be to improve early “patient labelling” to specialised consult services such as PRS for example by defining conditions that automatically lead to PRS consults and at the same time encourage referring physicians to pre-inform PRS before transferring a patient to the ED when PRS consult is highly likely or the reason of referral. Further, some patients might bypass ED completely in a standardized fashion. For example, most patients with hand fractures, a diagnosis that accounts for a high proportion of plastic surgery (PS) consults, could be directly referred to the daily PS emergency clinic from the referring physician. Therefore, information about existence of this service would need to be thoroughly spread among physicians and clinics within the GTA and likely emergency clinic capacity would need to be increased. In fact, only a small proportion of fractures (eg, open fractures) truly needs emergency assessment and intervention. For the vast majority of patients with hand fractures, assessment could be delayed to the next day as long as the referring physician is able to immobilize with a splint. Such a new practice would reduce ED workload and at the same time improve patient care with direct access to specialist care.
Targeting efficiency of triage, time to referral to consult services, and overall LOS would also help reducing the high number of after hour consultations (25%) found in our analysis. Not only current labour regulations are forcing us to address after hour consultation on call with respect to resident’s work load and educational exposure on the post call day which is by far not an issue in PRS training. A Canadian multicentre evaluation on general surgery ED consultations, for example, found 18% of consults happing between midnight and 6 am 16 suggesting at least comparable work load to our analysis. On the other hand, it goes without saying that after hour consultations will never be eliminated in a tertiary care paediatric ED due to the tertiary care character that naturally involves long distance transfers as shown in our analysis as well with longer patient transfer times in after hour consults. Taking efforts to optimize ED after hour functionality should be able to significantly reduce the number of after hour ED visits and thus potentially even allow consult services to provide home call versus in house call which meets predilection of Canadian PRS residents, who perceive home call superior to in house call with respect to education and quality of life and at the same time equal for patient care. 17
Referral Appropriateness
Assessing referral appropriateness objectively has been described to be difficult in several publications with respect to PRS consultations but also other disciplines, mainly due the lack of consistent criteria. 1,16,18- 20 In our study, all ED consultations were rated by PRS trainees as conditions managed within the scope of PRS practice. However, 9% were rated as inappropriate with respect to the level of urgency, and the potential to defer care to a PRS outpatient clinic the next day. Referrals were also deemed inappropriate if they were autonomously manageable by a fully trained paediatric emergency physician and felt that the expertise of a paediatric PRS consult service was not necessary. In the literature, others have used different criteria to define referral appropriateness. This includes the percentage of patients needing surgery, admission to the PRS service, or a follow-up appointment in the PRS outpatient clinic. Applying this criteria to our study would indicate that 94% of our referrals were appropriate, which is superior to the results reported by Urso-Baiarda 2 (66%)and Gorman and colleagues (70%). 5 Education feedback intervention performed between the 2 assessments did not lead to further improvement of referral appropriateness in our analysed population, likely because of the already existent high accuracy in combination with the knowledge and the difficulties to measure objectively.
Quality and Availability of Sedation
As expected, PRS consults frequently involved interventions, most of them under sedation. Due to additional logistics (need for extra material, room, etc) and oftentimes specialized personnel (educated ED staff, respiratory therapists) required to provide sedation the necessity for interventions naturally prolongs PRS consults. Our data analysis showed and a documented 1 to 2 hour delay for sedations to be started from indication and scheduled time in almost half of the cases. Reasons for the delay were identified to be mainly unavailable ED staff and/or respiratory therapists and rarely unavailability of the PRS trainee or other reasons, thus suggesting inadequate ED staff and respiratory therapists resources, especially after hours when the likelihood of a PRS consultation to require an intervention (with sedation) was found to be even higher. Further analyses are needed to minimize unnecessary delays. Solutions might involve expansion of the sedation services in the ED and/or within the PS service on the next day, since at least some sedations might be delayed till then. Both solutions would definitely involve recruiting further personnel resources and new logistics (eg, changes in shift schedules for ED staff and respiratory therapists, increasing the number or respiratory therapists for the ED).
Unfortunately, our analysis revealed a high percentage (almost 60%) of sedations that were rated inadequate with minor or major difficulties encountered, mostly such as the procedures had to be hold for repeated drug dosing due to inadequate sedation. Quality rating of sedations did not improve following education feedback intervention. Potential factors to influence quality of sedations are numerous, most obvious ones include appropriateness of drugs used and drug dosing but the list is by far not limited to these. Ketamin in combination with midazolam was mainly used for the interventions/sedation in our population. Those are common and popular players for sedations in paediatric EDs around the globe. 21,22 However, Kannikeswaran and colleagues 23 showed that ketamine dosing directly influences efficiency of procedural sedation in paediatric EDs as well as physician satisfaction with the procedural sedation while there is a fair range of dosing that does not influence safety or number of adverse events 23 suggesting evaluation of dosage guidelines in our ED. The current literature is crowded with reports and recommendations about sedation in paediatric EDs. 22,21 Numerous practices are cited, but it appears that every institution has to implement individual guidelines rather than blindly follow a single “best” protocol. We hope to collaborate with our ED leaders to review expectations of PRS team members toward intervention in the ED as well as to identify limitations of the current practice from an ED and PRS staff perspective.
Study Limitations
Our analysis is based on a 3 months pre-intervention period followed by a 3 month post-intervention period. To fully understand and display the fluctuating business of a paediatric ED, a longer period should be evaluated. All results were documented and collected by the directly involved plastic surgery trainees which makes a bias clearly possible. Since this is a single centre experience, our findings cannot be directly transferred to other paediatric EDs with likely different logistics, on call structures, as well as staff resources, but it may motivate others to analyse their current practice and collaboration.
Conclusion
Hereby presented data gives the most detailed insight into daily practice of PRS and ED collaboration in a tertiary care paediatric hospital published so far. Plastic and reconstructive surgery is a busy consult service in a paediatric ED. Logistics around PRS consults, high overall ED LOS, and unsatisfying quality of sedation were identified as the main areas for improvement. Education feedback intervention in between data analyzing periods was not sufficient to achieve significant improvements and therefore demand further efforts. Direct communication of expectations of care by both collaborating teams will be essential as well as cultivating a permanent open dialogue between PRS and ED professionals and leaders to further improve current practice of collaboration and thus patient care and satisfaction of involved professional teams.
Acknowledgments
The authors are very grateful toward the PRS fellows and residents who thoroughly collected above data on call as well as to the ED team to openly welcome our efforts and allow optimizing PRS/ED collaboration.
Authors’ Note: The study was registered and approved by the SickKids Quality Management Department as a QI initiative and subsequently obtained Research Ethics approval to retrospectively review and publish these data.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Emily S. Ho, PhD https://orcid.org/0000-0003-4082-1770
Christopher R. Forrest, MD https://orcid.org/0000-0002-2934-9690
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