Seattle Children’s Hospital (SCH)

SCH adopted the Rapid Medical Assessment (RMA) Model commonly used in adult emergency care, which has been shown to decrease length of stay and time to provider. ^{Reference Traub, Wood and Kelley8,Reference Furmaga and McDonald9} Patients meeting criteria (categorized as Emergency Severity Index level 3, 4 or 5, who likely need minimal ED resources) were quickly evaluated by an ED attending and/ or advanced practice practitioner in flexible spaces such as hallways or waiting areas, where diagnostics and treatments were initiated without undergoing step-wise triage and serial trainee evaluations. The SCH PED also liberalized discharge criteria for patients in whom test results would not change disposition; examples include patients awaiting rapid strep antigen test, urinalysis, or viral studies. Such patients were discharged to the lobby or home while awaiting results. For those discharged home awaiting results, either the RMA team or the pre-existing communications center updated families and sent prescriptions as needed. The RMA model was also utilized for early care initiation for patients needing more extensive workup when an ED room was not immediately available. In this circumstance, patients were brought to a temporary space and had workup started (e.g., blood drawn, IV placed, imaging studies ordered, or medical clearance completed for mental health evaluation) and then returned to the ED lobby to wait for an ED room. Since these processes rethink the traditional flow of an academic ED, continued training and frequent check-in with staff were key to ensuring success of adoption and incorporation of iterative changes.

Children’s Hospital Colorado (CHCO)

CHCO implemented a front end ‘Intake’ process in 2015, in which the triage rooms were converted to full patient care rooms in order for a physician to assess a patient as soon as possible after arrival to initiate and expedite their evaluation. When patients arrived at the PED they were initially met by a ‘Sort’ nurse who assigned an ESI level and determined the destination of the patient: to Intake or to the main area of the ED based on specific inclusion and exclusion criteria. A pediatric emergency attending evaluated patients in Intake and further determined whether they could be discharged to home after a quick intervention, required to be seen in the main area of the ED as a ‘super track’ patient that would likely be discharged within an hour, or became a ‘main’ ED patient that would likely require significant further evaluation and management. As patient volumes increased, and ED capacity decreased, there was a significant need to maximize the use of the front-end area to evaluate, manage, and discharge appropriate patients to preserve capacity in the main area of the ED. Increasing the use of standing orders (protocols that allow nurses and medical assistants to order certain clinical tasks without having to first obtain a physician order) further improved this process. This included ordering of X-rays for minor trauma, ondansetron for vomiting with diarrhea, and ibuprofen/ acetaminophen for pain and/ or fever. Additional interventions were taken to aid with discharge of patients who would otherwise have been determined to be ‘super track.’ This included the splinting of minor fractures in intake, providing oral rehydration after ondansetron while in the waiting room, and completing simple diagnostic procedures such as rapid strep swabs, viral respiratory testing, and urinalysis.

SCH

At SCH, admission to the pediatric intensive care unit (PICU) previously involved a consult process for all potential patients meeting intensive care criteria. This consisted of an in-person bedside evaluation in the ED by an intensive care attending, fellow, or advanced nurse practitioner. Due to surge volumes, the PICU collaborated with the PED to implement a new expedited process which bypasses this consultation for patients meeting specific predetermined criteria, such as patients who are intubated, on inotropes, or newly started on positive pressure ventilation. Similarly, the disposition of patients to primary specialty service teams typically required subspeciality team acceptance prior to bed assignment. A previously designed but infrequently used ‘admission matrix’ model was revived to facilitate direct acceptance of patients meeting certain admission criteria to over 16 specialty services. For example, patients with new onset diabetes or adrenal insufficiency who met acute care criteria could start the admission process to endocrinology prior to detailed subspecialist consultation. For patients whose disposition was affected by delayed workup (such as an MRI), the general medicine service agreed to accept them prior to completion of the study.

SCH PED leadership increased notification of ED surges to key operational leaders (such as radiology, pharmacy, and inpatient departments) to improve situational awareness among departmental leaders and offload PED needs during active surge. For example, an inpatient nurse could be assigned to pick up their patient directly from the ED instead of waiting for ED transport. Several actions were linked with the surge alert including the ED team placing admit orders and additional nurses from the hospital being sent to the ED to assist. Cross-departmental staffing shortages have limited this strategy’s impact.

Children’s Hospital Los Angeles (CHLA)

Similar to other hospitals, admission of a patient from the ED at CHLA to an inpatient unit was a complex, multi-step process. The workflow for admissions during the pandemic was revisited and scrutinized to reduce redundancies, eliminate unnecessary steps, and improve efficiency. Instead of steps that were done sequentially, some steps were performed simultaneously, such as giving phone sign out by physicians and nurses to their respective inpatient counterparts. In addition, the work that environmental services provide to clean a room before a new patient can arrive was streamlined by making certain supplies accessible on each unit of each floor instead of one centralized storage area.

Another example of collaboration across departments at CHLA was the creation of the ‘ED Length of Stay (LOS) Alert,’ intended to trigger a house-wide alert to assist with ED decompression. The CHLA ED used a modified version of the National Emergency Department Overcrowding Scale (NEDOCS). When the NEDOCS score reached 140 (‘overcrowded’), an ED LOS Alert was triggered whereby ED patients who were waiting for COVID results before being assigned an inpatient bed were sent up as patients pending infectious status prior to the COVID result. The pandemic also allowed for improved collaboration between the ED and other sub-specialists on patients who did not require admission but who were seen in the ED and needed close outpatient follow up. For example, with uncertainty about new disease processes such as Multisystem Inflammatory Syndrome in Children and Post-COVID Vaccine Myocarditis, new protocols were developed with Cardiology to ensure standardized ED testing and management of such patients, as well as adequate post-ED care while balancing ED throughput and staffing constraints.

SCH

SCH PED implemented a bundle of operational and clinical tools to streamline care for patients presenting with mental health concerns. Physicians had historically relied on a team of specially trained Mental Health Evaluators (MHEs), who are professionals with Masters’ degrees in social work or counseling, for behavioral and safety assessment of patients, as well as for determining final disposition. This core team has proven to be essential in times of mental health patient surges. To streamline and improve collaboration between providers and MHEs, a mental health handoff tool to specify where each patient was in their evaluation process was created in the electronic health record to facilitate communication of care progression, barriers, and disposition. Given the frequently high volume of mental health boarders in the PED, a daily huddle with walk rounds was initiated with hospital and inpatient psychiatry leadership to review boarding mental health patients in the ED. A decommissioned space in the main hospital was redesigned, modified and simulated to be a calm, quiet boarding area for mental health patients awaiting inpatient psychiatry placement. This space was staffed by PED attendings, nurse practitioners, nurses and security officers. The main ED rooms are designed with a porch allowing visibility into two patient rooms from one spot; trained watch staff are able to complete 2:1 watch assignment. An overflow space was briefly opened where 6 lower acuity mental health patients were co-located using 2-3 staff members.

CHLA

All patients requiring inpatient psychiatry bed placement were transferred out, given that CHLA does not have its own inpatient psychiatry unit. Difficulty in outside placement due to lack of availability of psychiatry beds has been a long-standing issue, and was now further compounded by the mental health crisis. The PED continued to admit patients on psychiatric hold for more than 24 hours to the general medicine service if psychiatric placement could not be obtained within the timeframe.

CHCO

CHCO implemented a mental health patient surge plan for psychiatric emergency services for the main campus PED as well as the 2 CHCO network PED sites. Triggers to initiate the boarding patient surge plan included community mental health beds nearing capacity, CHCO inpatient psychiatric beds at capacity, and location specific triggers of total number of mental health patients present, number of boarding, or extended stay patients. Once triggers were met, a huddle was organized by ED leadership and consisted of ED Behavioral Health Counselors (BHCs), ED physician and nursing leadership, inpatient physician and nursing leadership, and nursing house supervisor. The BHC identified patient(s) who would be best supported in a secondary location such as an inpatient medical unit, or another CHCO ED location.

Considerations when determining which patients were safe and appropriate for the inpatient medical setting included behavioral observation level, use of seclusion or restraints, medical complexity, and aggressive behaviors, as well as history of elopement or impulsive behaviors, behavioral or development diagnoses, or active high-level self-harm. Strict attention was paid to the overall capacity of inpatient medical units so as to not overload these units with mental health patients and prohibit admission of medical patients.

In January 2022, CHCO announced the appointment of its first ‘Mental Health In-Chief’ across the entire hospital system. Like more traditional ‘Pediatrician In-Chief” and ‘Surgeon In-Chief’ roles, this new role became a critical partner to help shape the mental health vision, strategy, operations, and safety of the entire CHCO system, aiming to integrate pediatric mental health into all major hospital level decisions.