A Quality Improvement Project to Increase Nurse-initiated Care from Triage and Improve Timeliness to Care in the Pediatric Emergency Department

Introduction: Initiating care during emergency department (ED) triage is an effective way to decrease time to treatment. Triage nurse–initiated standing orders (SOs) are safe, evidence-based, and allow care to begin for patients before provider evaluation. We describe a multidisciplinary approach to increase the use of SOs across 2 pediatric EDs. Methods: Interventions for this quality improvement initiative were driven by frontline staff input and included education, fostering competition among nurses, individual feedback, and editing of SOs. The primary outcome measure was the use of SO per patient encounter, monitored using a U-chart. The secondary outcome measures were time to dexamethasone in patients with asthma and provider time to disposition for discharged patients with gastroenteritis or streptococcal pharyngitis, monitored by X-bar and S-charts. The process measure was the percentage of orders placed outside of SOs, monitored by a P-chart. The balancing measure was the length of stay for patients with gastroenteritis and streptococcal pharyngitis. Results: The rate of SOs improved from 165 to 234 per 1,500 patient encounters at the main campus and from 53 to 82 per 500 patient encounters at the satellite campus, each resulting in statistical process control chart centerline shifts. There was an improvement in the process measure at both pediatric EDs. Conclusions: SO use increased across the 2 campuses. SO use is associated with shorter length of stay, decreased time to medication, and decreased provider time to disposition for 3 specific patient populations. SOs improve throughput and can be used in the care of pediatric patients.