Standardization of Discharge Instructions by Age for Children Presenting to the ED With Mild Traumatic Brain Injury: A Quality Improvement Project.
Academic Article
Overview
abstract
INTRODUCTION: Mild traumatic brain injuries (mTBI) are common in pediatric emergency departments (EDs), but inconsistent use of diagnostic labels leads to variable discharge instructions, especially with regard to concussion. Lack of age-appropriate guidance can increase parental anxiety and ED revisits and hinder recovery. OBJECTIVE: This quality improvement (QI) initiative aimed to increase the proportion of mTBI patients receiving age-appropriate discharge instructions to 50% over 13 months in an urban pediatric ED. METHODS: An interdisciplinary QI team conducted an observational time series study with sequential experimentation at a quaternary academic medical center over 13 months. Using a key driver diagram, they created SMART aim, measures, and designed interventions which were tested through 5 Plan-Do-Study-Act (PDSA) cycles. Interventions included an educational curriculum, e-reminders, workspace materials, and pre-written electronic medical record (EMR) templates (smart phrases) for age-specific discharge instructions (0 to 5 y, ≥6 y), and parent surveys were used on a subset of sample families to assess knowledge, behavior, and anxiety post-discharge. Outcome measures included the percentage of age-appropriate discharge instructions provided and use of the new EMR smart phrase. Balancing measures tracked head computed tomography (CT) utilization, ED revisits within 14 days of discharge, and neurology referrals. Process control charts and rules to detect special cause variation were used to analyze data. We use descriptive statistics to analyze survey data. RESULTS: Among 1263 patients, age-appropriate discharge instruction rates improved from 36% to 56%. Smart phrases were used in 58% of relevant cases (n=628). No changes were observed in CT orders, ED revisits, or neurology referrals. Among 37 surveyed parents (28% response rate), 95% (n=35) found instructions helpful, and 68% (n=25) reported reduced anxiety. CONCLUSIONS: Implementing EMR smart phrases in a pediatric ED increased standardized, age-appropriate discharge instructions for children with mTBI. These low-cost interventions are scalable for broader ED use and other settings.
