O2168: Quality Improvement Initiative to Reduce Pediatric Emergency Department "Left Without Being Seen" Rates Utilizing a Vertical 3 Process

Purpose/Objectives: Prolonged triage-to-provider time increases Left Without Being Seen (LWBS) rates, which can lead to missed diagnoses, delayed treatment, and potentially life-threatening outcomes. Our Quality Improvement (QI) project aimed to reduce the Pediatric Emergency Department (PED) LWBS rate to less than 2% by decreasing triage-to-provider time.

Design/Methods: A multidisciplinary QI team was formed, including pediatric emergency physicians, nurses, administrative staff, and quality improvement specialists. Our QI project was conducted from January 2nd, 2024, to December 31st, 2024, at a pediatric ED in an urban academic hospital with a diverse population and patients ranging from ESI level 1 to 5.
The Plan-Do-Study-Act (PDSA) methodology was implemented following a needs assessment, which identified rising times from triage completion to provider assignment as a key area for improving LWBS rates. We hypothesized that, after the patients were triaged, delays occurred in placing them in an examination area due to a shortage of available beds. We repurposed our previously designated 'asthma room' into a space for examining lower-acuity patients in recliners instead of stretchers, now called the Vertical Patient Unit (Figure 1).
Multiple PDSA cycles were used to refine and optimize the triage process by implementing pathways, reinforcing nursing triage education, and continuously monitoring room utilization and staff allocation with feedback from staff and patients. We compared the outcome measures (triage-to-provider times, LWBS, and 48-hour return rates) from pre-intervention December 2023 to post-intervention January 2024- December 2024. Data were reported as weekly medians with Interquartile ranges (25%,75%). Comparisons between pre-and post-intervention periods utilized Mann-Whitney U (alpha = 0.05, all tests two-tailed).

Results: At initiation, the triage-to-provider assigned time was approximately 38.4 minutes (32.9, 45.3). Following the implementation of the Vertical 3 Process and multiple PDSA cycles, the median time to provider decreased to 22.3 minutes (16, 33.3).

Pre-intervention data (December 2023) showed LWBS rates had a median of 4.0% (95% CI: 2.0% to 4.0%). Post-intervention data indicated a decrease in the median LWBS rate to 1.2% (95% CI: 1.6% to 2.2%). The 48-hour ED bounce-back rate decreased from 3% (1.0%, 4.0%) pre-intervention to 1.7% (1.0%, 2.5%) post-intervention.

Conclusion/Discussion: We significantly reduced LWBS rates by decreasing triage-to-provider time through implementation of a Vertical-Patient-Unit. Ongoing PDSA cycles—such as relocating patients for sensitive exams and excluding neonates from the unit—addressed key barriers and will continue to support efficient and safe patient care.