Introduction 

The role of the Pediatric Emergency Service (PES) is crucial for public health. Providing critically ill patients with rapid access to emergency care is the primary function of emergency medicine; however, this function is overshad­owed by overcrowding in such services^(1,4). The quality of PES depends on the teamwork of physicians, nurses, lab­oratory staff, imaging services, and other departments or units^(2,3,4).

Overcrowding in emergency services is defined as a situation in which demand exceeds the capacity of physicians and nurses to provide quality care within a reasonable time⁽³⁾. The factors contributing to overcrowd­ing in emergency services can be divided into three groups. First, prehospital causes such as lack of care in pri­mary care services and transfers from regional hospitals. Second, causes related to the emergency service itself, including delays in the triage system, lack of medical or nursing staff, delays in laboratory or imaging tests, and de­lays in patient admission. Lastly, hospital factors, such as patients remaining for extended periods in the emergency service while awaiting inpatient bed availability⁽⁵⁾.

The hospitalization process for a patient from the emergency department is complex and often delayed. A patient may remain in the emergency service for more than 24 hours^(2,5).

The Pediatrics Department at Hospital General San Juan de Dios has a hospitalization capacity of 200 beds and 46 intensive care beds, with an occupancy rate great­er than 75%, varying throughout the year and reaching rates above 156% during peak periods. The hospitalization process from the emergency department includes the fol­lowing steps: documenting the patient (admitting them into the hospital’s clinical registry system), triage per­formed by the physician, and admission to the emergency department, which includes the following areas: obser­vation, respiratory therapy, shock room, procedure area, traumatology, and pediatric surgery. Patients admitted to these areas only use an emergency sheet (a document used exclusively for emergency admission). However, if the patient requires hospitalization, a complete written admission must be performed, since there is no electronic medical record system available. This procedure takes approximately 75 to 90 minutes. Furthermore, laboratory tests and imaging studies are performed when necessary. Medications are administered, nursing care is provided, and finally, the nursing staff requests a bed in the inpatient area. Completing this process can take from 8 hours up to 48 hours, causing overcrowding in the emergency depart­ment and discomfort for patients and their families. Sev­eral points within this process can be modified to reduce patients’ waiting time in the emergency department.

The objective of this project was to improve the hos­pitalization admission process. Our aim was to reduce the time required to complete the written admission from 75 minutes to 30 minutes in the PES by November 30, 2023. The intervention began on September 1 and ended on November 30, 2023, consisting of designing a short­ened written admission form, thereby reducing the time residents needed to complete it.

Materials and methods

Context

This study was conducted in the PES of Hospital General San Juan de Dios, a tertiary-level hospital forming part of the public health system, which handles an aver­age of 60,000 consultations per year. The emergency staff consists of: one emergency section chief, three pediatricians from 7:00 to 15:00 and two pediatricians from 13:00 to 20:00, Monday through Friday. Additionally, there are three pediatricians per shift from 16:00 to 7:00, and the residency team rotates monthly: one third-year resident, one second-year resident, and two first-year residents.

First-year residents are responsible for complet­ing the written admissions, which must be handwritten using the Weed method (problem-oriented medical record). The hospital does not have an electronic medical record system.

Interventions

A multidisciplinary team was formed consisting of pediatric emergency physicians, residents, and nursing staff. Data collection was carried out Monday through Friday between 7:00 and 13:00. A pediatric emergency physician recorded the time it took residents to complete the written history. Baseline data prior to the intervention were collected from September to November 2023.

Using the improvement methodology model, process mapping was conducted to identify key factors influencing delays in patient admission to inpatient units (Figure 1).

Using the PDSA cycle (Plan, Do, Study, Act), the team initially changed the admission model, designing a short­ened admission note containing only the current illness and significant medical history. The full admission note would later be completed in the inpatient units by the cor­responding medical staff. Additionally, one physician was assigned exclusively to complete the written admissions without interruptions. Another intervention used to reach the objective was to avoid waiting for laboratory or imag­ing results before completing the admission and allowing nursing to proceed with their responsibilities.

Analysis: All collected data were placed on a run chart, and SPC rules were used to analyze special-cause varia­tion. Sequence run charts were used.

The reference period was September to November 2023. The intervention period was October and November 2023.

Significant changes in the measurements (i.e., special-cause variation) were identified using run chart rules or SPC, and the centerline was recalculated, showing improvement in the process.

Ethical considerations

The work was approved by the Hospital Research Committee.

Results

A total of 189 admissions were analyzed between 7:00 and 13:00, Monday to Friday, from September 10 to November 25, 2023. In the first 50 patients, the time needed for a resident to complete an admission averaged 75 minutes. After implementing the shortened admission and assigning a physician exclusively for this task without interruptions, the time was reduced to 26 minutes.

As shown in Figure 2, the time used to complete patient admissions was observed over an 11-day period. Our goal is indicated by the green dotted line. At the start of the intervention, an improvement was observed, with times ranging between 80% and 100% of the expected time. Later, a decline to pre-intervention levels was noted. Upon investigation, this coincided with a non-working shift and a new resident who had not been informed of the process change. This demonstrates that all improve­ments implemented must be communicated to every team member. Once the intervention was explained to the new resident, the times again remained above our goal (80%). Another decline occurred due to incorrectly completed admissions that had to be rewritten, doubling the processing time.

This chart is a valuable tool for improvement imple­mentation, as it clearly visualizes whether the proposed goal has been reached.

Discussion

Implementing a shortened written admission complet­ed by a pediatric resident assigned exclusively to this task was successful. It is known that delays in transferring pa­tients from the emergency department to inpatient units are influenced by several factors. In the study by Nathan R. Hoot et al., three general causes of emergency department overcrowding are described: input factors, throughput factors, and output factors. Among the throughput fac­tors, insufficient medical staff or trainees directly affects overcrowding.

Our SMART objective was to reduce the time required for residents to complete a written admission, successfully lowering it from 75 minutes to 26 minutes.

During the project, two declines were observed in the run chart: the first due to rotation transition, when the incoming resident was unaware of the implemented mea­sure; and the second due to incorrectly completed admis­sions, which required correction and delayed the process. After identifying these causes, residents were informed of the new protocol for shortened histories, resulting in im­provement in admission times.

The improvement methodology allowed the team to initially identify issues amenable to optimization through small interventions, which in the future will lead to better care for patients. By reducing the time required for resi­dents to complete written admissions by more than half, patient waiting time decreases; the transfer process to inpatient areas is expedited; patients receive medical treatment and nursing care faster; and residents have more time available for other service tasks or even to rest or eat.

A long-term improvement would be the implementa­tion of computers and an electronic medical record sys­tem in the emergency department. This measure would streamline processes, although it requires investment from the Ministry of Health. Relevant administrative actions were initiated, and implementation is expected in the future.

Limitations during implementation included conduct­ing the improvement during morning shifts, where more medical staff is available and processes are naturally faster. Implementing the same intervention during afternoon and night shifts—when patient volumes are higher—would likely have a greater impact. Additionally, the measure­ment period was only three months. Assessing the impact of this intervention throughout different seasons would be important, given variations in patient influx.

Conclusions

In our study, the intervention reduced the time required to complete the written admission for emergency-to-inpatient transfers from 75 minutes to 26 minutes, thereby helping accelerate the admission process and reduce over­crowding in the emergency service.

Funding

This study did not require external funding.

Conflict of Interest

The authors declare no conflicts of interest.

Author Contributions

The authors certify equal contributions to the concep­tion, design, scientific and intellectual content, and writing of the manuscript.

References

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