O1026: Using Quality Improvement to supercharge throughput metrics of pediatric emergency and urgent care patients

Purpose/Objectives: During the 2022 respiratory surge, our institution separated our physically combined pediatric emergency department (ED) and urgent care (UC) into two distinct spaces, while maintaining a combined entrance and triage system. Because of the success of this change, we reopened our “relocated urgent care” (RUC) for the 2023/24 respiratory season, making it permanent in the fall of 2024. UC, open from 11am to 8pm, accounts for 45% of our total daily patients, and the RUC sees 85% of these. However, during the 2023/24 season we identified challenges in our UC throughput processes that affected both ED and UC patients. This led to increased left without being seen (LWBS) rates, increased wait times, and dissatisfaction of both patients/families and staff.

Design/Methods: We held a large, multi-disciplinary Kaizen event where we process- and valuestream-mapped the current state, defined waste, used fishbone diagrams to identify problems areas, and generated solutions. A key driver diagram prompted creation of three QI working groups to focus on 1) registration and patient flow, 2) RUC closing time processes, and 3) improvement of the current fast track (FT) process. Each group created a bundle of interventions that were put in place prior to RUC reopening in October 2024 (Figure 1). Additionally, our ED/UC provider and nursing leadership changed shift timing to better align with patient arrival patterns. Our aim was to improve LWBS rates from a peak of 12.2% in 2023/24 to our institutional goal of < 5% by the end of the 2024/25 respiratory season. Process measures included ED and UC waiting room (WR) time at UC close and percentage of UC patients discharged after UC close. Balancing measures included both ED and UC length of stay (LOS).

Results: We compared several throughput metrics from the 2023/24 respiratory season to the 2024/25 respiratory season. Despite higher patients volumes in 2024/25, we improved LWBS rates from a peak of 12.2% (weeks 6-10) in 2023/24 to a peak of 4.3% (weeks 15-19) in 2024/25, with significant reduction to < 3% for much of the 2024/25 season (Figure 2a/2b). Process measures and balancing measures were also improved (Figure 2c). Weeks were counted from the date the RUC opened each year (Oct 28 in 2023, Oct 21 in 2024).

Conclusion/Discussion: Using QI methodology, we were able to streamline our patient flow process for RUC patients which improved throughput metrics for both the ED and UC, allowing us to see more patients more efficiently. Although the nature of our combined ED/UC site is unique, our interventions had minimal cost with few new resources needing to be allocated, making similar changes applicable in another setting. We plan to continue to refine these processes to ensure maintained efficiency at our institution.