BACKGROUND AND OBJECTIVES

Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement.

METHODS

At a tertiary children’s hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates.

RESULTS

Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates.

CONCLUSIONS

The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.

Discharge from the emergency department (ED) is an important and complex process of transition to outpatient care. It starts with the medical team’s recognition and confirmation of a patient’s readiness for discharge, including a review of test results, vital signs, and reconciliation of outstanding orders. After establishment of discharge readiness, the care team conveys the diagnosis, test results, after-care instructions, and follow-up plan to patients and families. Gaps in care related to discharge from general EDs have been the focus of a large body of literature targeting key elements such as team communication and patient discharge instructions.14  Similar gaps exist for pediatric EDs, and others have targeted these same areas for improvement.58  However, a common theme has been the focus on individual components of the intricate discharge process, such as multidisciplinary communication or prescription errors. To our knowledge, no ED-specific studies have addressed the entire process to ensure patient discharge readiness, from both the provider and patient perspective.

In 2018, our pediatric ED noted a series of discharge-related events that underscored a need to improve our discharge process. Although most events were of low severity, they included a total of 4 preventable serious safety events (SSEs), which culminated with the return of 1 patient in critical condition after an abnormal diagnostic test result went unrecognized. This event prompted local leaders to prioritize development of a new comprehensive discharge process. The primary objective was to eliminate preventable SSEs and improve family perception of communication at time of discharge.

We conducted a quality-improvement (QI) initiative at a 400 bed, freestanding academic children’s hospital with 60 000 annual ED visits and 60 ED beds. Approximately 80% of ED patients are discharged. There are 70 pediatric emergency attending physicians, 18 medicine fellows, 250 resident physicians rotating annually, and 175 nurses and clinical assistants. We use Cerner PowerChart electronic health record (EHR) (North Kansas City, MO).

In July 2018, we assembled a multidisciplinary improvement team consisting of ED leadership, pediatric emergency medicine fellows and attending physicians, nurse educators, bedside nurses, a nurse manager, a data analyst, a QI consultant, and a physician EHR specialist. Parent advocates provided feedback early in the project. We chose the model for improvement and focused efforts on creating a key driver diagram to delineate the problem and potential solutions.9  We identified 4 key drivers of a safe discharge process: multidisciplinary care coordination; task tracking with an emphasis on reconciliation of all testing and treatment components; communication of how to care for the child at home; and team engagement in the value of high-quality, safe discharge (Fig 1). To support our change strategies, we created 4 separate working groups to provide organization and accountability for the efforts: (1) data and measurement, (2) marketing, (3) education and feedback, and (4) documentation with EHR enhancement.

FIGURE 1

Discharge process key driver diagram.

FIGURE 1

Discharge process key driver diagram.

Close modal

Improved Multidisciplinary Care Coordination and Task Tracking

To facilitate care team communication, we created a paper discharge checklist, dubbed the Golden Ticket, to guide the new process (Supplemental Fig 6). Checklist items incorporated both physician- and nurse-specific tasks necessary to ensure discharge readiness, including: a review of timely vital signs, test results, outstanding orders, and accurate patient identification on paper-discharge instructions. A main component of the Golden Ticket was the expectation for shared checklist review during a registered nurse (RN)/Doctor of medicine (MD) huddle. Provider signatures served as acknowledgment of accountability for task completion and an indication that the huddle occurred. At the end of the ED visit, this completed Golden Ticket was handed to the patient/caregiver, along with the written discharge instructions, and subsequently collected by the administrative team at the ED checkout desk for manual review. We chose a paper tool because it was easily and rapidly deployable, with the added advantage of supporting quick turnaround iterations. Additionally, our nurses have substantial experience with paper tools and we believed the act of reviewing the physical ticket together would support the huddle.

Parental Education

Our second intervention focused on improving patient and caregiver understanding of discharge instructions. We used a scripted tool called the “5 Things To Know Before You Go,” located on the reverse side of the Golden Ticket. This tool outlines 5 important questions regarding diagnosis and postdischarge care, as a reminder to providers to review and facilitate more structured teaching at time of discharge (Supplemental Fig 6).10 

Engagement and Organizational Culture Change

Our third group of interventions centered on raising awareness of the value of a high-quality and safe transition to outpatient care. This was critical in that improvement necessitated a process change across a large, complex environment. Capitalizing on local context that supports a strong culture of improvement, we followed the Pathman awareness-to-adherence model of implementation.11  To foster awareness, the marketing subgroup planned announcements at staff meetings, distribution of posters, creation of a “QI announcement board” to display the process, and placement of signs on computer monitors. Targeted reminder e-mails to scheduled RN and MD providers were sent at the start of the initiative. Staff members completed a mandatory, Web-based learning module that highlighted safety event stories and reinforced the need for a standardized process. Finally, ongoing awareness was promoted through frequent, departmentwide electronic communications sharing audit and feedback data regarding the performance and adoption of the new process.

Once marketing efforts raised awareness, we focused on agreement, adoption, and adherence to new practices. To do this, we developed Plan–Do–Study–Act (PDSA) cycles, each undergoing several iterations. The first set of PDSA cycles consisted of rollout of the Golden Ticket. To gain agreement, we solicited feedback for ease of use and content, modifying it iteratively. The next set of PDSA cycles clarified flow and roles in the process, thus promoting standardized nurse engagement in the discharge instruction process, which previously was primarily a physician task. This process was trialed in all areas of the ED, including attending-only teams and those with trainees and/or advanced practice providers. We surveyed providers again to assess both usability and flow. We promoted further adoption with ice cream socials, where we elicited feedback via a short paper survey. Lastly, throughout the effort, we employed Golden Ticket “champions” who promoted adherence to checklist use and addressed questions during clinical shifts.

Study of the Interventions

We included all patient discharges from the ED. Data were obtained from the hospital’s data warehouse (Children’s 360, Microstrategy Corporation, Tysons Corner, VA), patient safety data collected in the ED, and Press Ganey (Press Ganey Associates, South Bend, IN) patient survey.12,13  All outcome, process, and balancing measures were tracked on a monthly basis.

Outcome Measures

There were 2 primary outcome measures:

  1. number of days between preventable, discharge-related SSEs; and

  2. percentage of patients/caregivers rating “information you were given about caring for your child at home” as very good (highest possible rating).

This was the best, institution-specific Press Ganey survey question directly related to discharge preparedness from the patient perspective. A secondary outcome measure was number of days between preventable, lower-level, or precursor events.

Our event reporting designates SSEs as those resulting in severe temporary harm, moderate or severe permanent harm, or death. Low-level precursor reports represent near-miss, no detectable harm, or minimal harm events. Although a frontline staff member may provide details of the event and offer suggestions of preventability or level of harm, final determination is made by a safety manager. Review also includes the categorization of an event as related to discharge, defined as an omission of critical discharge-related functions requiring postdischarge intervention or a return visit.

Process Measures

Process measures included the proportion of discharged patients with a completed Golden Ticket (including MD and RN huddle acknowledgment via signatures) and vital signs (temperature, heart rate, respiratory rate) taken within 60 minutes of discharge.

Vital sign data used the time stamp correlating to vital signs recorded in the EHR within 60 minutes before the patient’s checkout from the ED. For this measure, a 100 patient sample was used to avoid overdispersion, given the large number of discharged patients.

Balancing Measures

Balancing measures were:

  1. ED length of stay (LOS) in minutes for discharged patients;

  2. proportion of patients who returned to the ED within 72 hours after discharge and were hospitalized; and

  3. proportion of patients who returned to the ED within 72 hours after discharge and were discharged again (excluding encounters related to homelessness, because patients typically returned until housing secured).

Analysis

We tracked changes over time using statistical process control methodology and used standard rules according to the Healthcare Associates in Process Improvement methodology to determine special cause variation.14  Statistical process control charts were created using Statistical Quality Control pack version 7.0 (PQ Systems, Dayton, OH).15  For the secondary outcome measure, we used a g-chart to display infrequent, preventable low-level events. We used a percentage or p-chart for process metrics.

This project was considered QI by the Performance Excellence Group in the Department of Pediatrics at our institution and exempt from review by the institutional review board.

During the preintervention period, July 2016 through June 2018, there were 97 413 ED discharges. During the intervention period, July 2018 through February 2020, there were 82 193 ED discharges.

There were no preventable, discharge-related SSEs throughout the study period ending in February 2020. This was compared with 4 discharge-related SSEs in the 2 years preceding our study period, all of which were deemed preventable. Moreover, despite the end of the study period, we remain without preventable SSEs as of August 28, 2022. There was no change in patient/family report of the “quality of information given at discharge” during the study period, which was sustained at 62% (Fig 2). After implementation, low-level event frequency improved from a mean of 11 to a peak of >150 days between events (Fig 3).

FIGURE 2

Press Ganey top box score for “Information you were given about caring for your child at home.”

FIGURE 2

Press Ganey top box score for “Information you were given about caring for your child at home.”

Close modal
FIGURE 3

Number of days between low-level gaps in care related to the discharge process.

FIGURE 3

Number of days between low-level gaps in care related to the discharge process.

Close modal

We observed steady uptake in the adoption of the Golden Ticket over the first few weeks, surpassing our initial goal of 70% completion with a rise to a sustained 89% with only a brief decrease before another upward shift to 94% in October 2019 (Fig 4). We identified special cause variation resulting in a shift in proportion of patients with vital signs obtained within an hour of discharge, from 61% in the preintervention period to 83% in the intervention period (Fig 5).

FIGURE 4

Percentage of patients with completed discharge checklist.

FIGURE 4

Percentage of patients with completed discharge checklist.

Close modal
FIGURE 5

Percentage of patients with vital signs within 60 minutes of discharge.

FIGURE 5

Percentage of patients with vital signs within 60 minutes of discharge.

Close modal

There was no change in median LOS (mean 185 minutes), rate of return visits within 72 hours resulting in hospitalization (mean 1.1%), or rate of return visits within 72 hours resulting in discharge (mean 2.4%).

A QI intervention incorporating a completely new discharge process to ensure interdisciplinary collaboration and standardized communication with families was associated with the elimination of preventable, discharge-related SSEs in a pediatric ED. We surpassed our goal of eliminating these events during the study period ending in February 2020, with no preventable, discharge-related SSEs reported as of August 28, 2022. This was compared with 4 discharge-related SSEs in the 2 years preceding our study period, all of which were deemed preventable. Of note, there was no change in caregiver report of the quality of information given at discharge. We noted rapid uptake in the use of the Golden Ticket and acquisition of vital signs within 1 hour of discharge, without an increase in LOS. Importantly, there were longer intervals between preventable, low-level, discharge-related events, suggesting additional safety gains related to the new process.

We believe there were several factors that contributed to the improvements.9  First, we began by sharing a preventable SSE as collective motivation for change. Our multidisciplinary approach, which incorporated caregivers, allowed inclusion of a variety of perspectives. We believe this approach fostered agreement; feedback-driven iterative changes helped support adoption. The predefined organizational structure of the improvement process helped clearly identify roles and ensured accountability from a diverse group of project members. Moreover, our long-established, multidisciplinary quality and safety committee, with support from divisional leadership, has fostered the value of event reporting and QI. Additionally, our robust data infrastructure allowed ready data access and analysis for rapid cycle change. In all, we were primed for a wide-reaching effort in the context of a culture of safety, improvement capability, and a motivation for change.

We chose an easily deployable paper tool to anchor a multidisciplinary huddle to enhance discharge communication. Interdisciplinary huddles are a well-established form of improving engagement.1620  A recent systematic review of literature around multidisciplinary safety huddles noted overall favorable outcomes.21  We hypothesized that, by formalizing a process whereby the physician and nurse were physically brought together before discharge, we would support communication and thereby minimize opportunities for error. This causal pathway was built on the knowledge that use of checklists and huddles can improve efficiency and ensure consistency and completeness in processes across disciplines.2224  Still, we were aware that not all checklists are effective or helpful.25  Although we knew that nonspecific “team talk” is not a traditional strength of checklists, we believed a discharge-focused conversation during an in-person huddle, anchored by the paper tool, would drive success. To be effective, we were mindful of the number and importance of each checklist item, focusing on the few but important tasks at risk for omission when determining discharge readiness.

We were disappointed that there was no change in the Press Ganey measure around information given at discharge. We were aware of the challenges in improving this rating solely as a result of our project, and hypothesize that the focus on the Golden Ticket addressed only a portion of the overall discharge experience.

Our initiative adds to the literature in that it addresses many components of the discharge process, including: standardization of discharge readiness, improved multidisciplinary communication, and support of parental comfort in transitioning care to home. Many pediatric institutions have addressed safe discharge from inpatient to outpatient settings, including the use of discharge bundles or emphasis on discharge counseling.2628  Mallory et al implemented a multisite transition bundle, with a transition readiness checklist, caregiver teach-back, timely medical provider handoff, and postdischarge phone call, showing improvement in key process measures.29  More recently, Uong et al examined a standard discharge-counseling framework, resulting in significantly improved caregiver comprehension of discharge instructions.30  From the ED perspective, a report from the Johns Hopkins University Armstrong Institute for Patient Safety and Quality, in collaboration with the Agency for Healthcare Research and Quality, outlines the main characteristics of a high-quality general ED discharge, including patient education, post-ED discharge care, and outpatient coordination of care.31  However, this comprehensive guide does not fully address discharge readiness from the provider perspective, nor specific concerns of the pediatric population. Most of the available literature around discharge, especially from the ED, focuses on singular aspects of the discharge process. For example, Vukovic et al led a successful effort to improve vital sign acquisition at ED discharge, but failed to show a decrease in 72 hour return visits.32  Other studies have focused on addressing prescription errors.3335  Martin et al aimed to improve provider communication within a pediatric ED by implementing a structured joint patient evaluation and huddle, and demonstrated improved communication, teamwork, and nurse satisfaction.36  Our efforts build on these findings, with an aim for high-quality discharge that starts with the initial recognition of patient readiness. To do this, we incorporated innovative usage of a discharge checklist and huddle that support and facilitate the vital multidisciplinary communication among team members. We believe that this, coupled with raising awareness of the value of a robust multidisciplinary process and strong socialization around a major event, led to the improvement in the number of preventable SSEs. As such, we believe this project is of importance to pediatric emergency medicine, inpatient, and office-based providers at the vulnerable time of care transition.

Although we have achieved our primary aim, we also encountered challenges. One involved engagement in restructuring a process which had traditionally been sequential physician-then- nurse activities, rather than a joint huddle. Some providers worried it could delay discharge, and others did not initially see value warranting additional coordination at discharge. To mitigate concerns, we shared data and highlighted patient stories (both failures and near-misses avoided by the huddle). Another challenge centered on incorporating the Golden Ticket/huddle into the workflow. We used Swim Lane maps to show both the existing flow versus improved design, enlisting frontline champions to help guide the new structure. A third obstacle was how to streamline communication to families. By including the 5 Things To Know Before You Go on the Golden Ticket, we were able to engage and empower nurses to supplement information given by physicians.

Our project has several limitations. First, this effort was conceptualized and implemented at a single pediatric institution, so generalizability may be limited. We have a robust QI and safety infrastructure and culture, primed to support improvement. Although strong infrastructure may not be available at all institutions, we believe a simple discharge checklist and huddle can be translatable to other settings. Second, although we tracked a signed discharge checklist for each patient encounter, we are unable to verify whether an actual huddle between MD and RN providers occurred. However, on the basis of the decrease in gaps in care, increase in discharge vital signs, and provider surveys, we believe the care team was coming together to review key items on the Golden Ticket. Third, we relied on voluntary event reporting within the ED for our main outcome measure, which is dependent on providers and staff. Although we were not aware of preventable SSEs by other means, we may have missed patients who returned to a different ED. Lastly, the determination of “preventability” of events might not be entirely objective; however, final designation is made by a third-party safety manager.

In summary, we successfully implemented a new discharge process in a large children’s teaching hospital. We demonstrated the potential power of a standardized, checklist-guided process that emphasizes interdisciplinary collaboration and clear communication with families. Although simple in design and implementation, it proved effective in reducing preventable SSEs related to ED discharge.

Further enhancements, including the transition to an EHR-based checklist structure, may offer a more efficient and generalizable option for improving the safety of pediatric ED discharge.

We thank John J. Porter, MBA, as well as our data analysts, parent advocates, nurses, clinical assistants, advanced practitioners, and doctors in the ED for their assistance and involvement in this QI initiative.

Dr Niloufar Paydar-Darian conceptualized and designed the study, designed the data collection instruments, coordinated data collection and intervention implementation, drafted the initial manuscript, and revised and reviewed the manuscript; Dr Anne Stack conceptualized and designed the study, designed the data collection instruments, coordinated data collection and intervention implementation, and critically reviewed and revised the manuscript; Ms Volpe, Ms Hickey, Ms Toomey Lindsay, Ms Moriarty, and Ms Falvo conceptualized and designed the study, designed the data collection instruments, reviewed data collection, coordinated intervention design and implementation, and reviewed and revised the manuscript; Ms Gerling performed and supervised data collection, conceptualized final interventions, and reviewed and revised the manuscript; Ms Seneski conceptualized and designed the study, designed the data collection instruments, performed data collection, conceptualized intervention implementation, and reviewed and revised the manuscript; Drs Eisenberg, Hudgins, Portillo, and Creedon conceptualized and designed the study, designed the data collection instruments, coordinated data collection and initial interventions, and reviewed and revised the manuscript; Dr Perron conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection and all intervention design and implementation, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

ED

emergency department

EHR

electronic health record

LOS

length of stay

MD

Doctor of medicine

PDSA

Plan–Do–Study–Act

QI

quality improvement

RN

registered nurse

SSE

serious safety event

1
Mazzocato
P
,
Forsberg
HH
,
Schwarz
U
.
Team behaviors in emergency care: a qualitative study using behavior analysis of what makes team work
.
Scand J Trauma Resusc Emerg Med
.
2011
;
19
:
70
2
Drake
K
,
McBride
M
,
Bergin
J
,
Vandeweerd
H
,
Higgins
A
.
Ensuring safe discharge with a standardized checklist and discharge pause
.
Nursing
.
2017
;
47
(
8
):
65
68
3
Schenhals
E
,
Haidet
P
,
Kass
LE
.
Barriers to compliance with emergency department discharge instructions: lessons learned from patients’ perspectives
.
Intern Emerg Med
.
2019
;
14
(
1
):
133
138
4
Hoek
AE
,
Anker
SCP
,
van Beeck
EF
,
Burdorf
A
,
Rood
PPM
,
Haagsma
JA
.
Patient discharge instructions in the emergency department and their effects on comprehension and recall of discharge instructions: a systematic review and meta-analysis
.
Ann Emerg Med
.
2020
;
75
(
3
):
435
444
5
Samuels-Kalow
M
,
Rhodes
K
,
Uspal
J
,
Reyes Smith
A
,
Hardy
E
,
Mollen
C
.
Unmet needs at the time of emergency department discharge
.
Acad Emerg Med
.
2016
;
23
(
3
):
279
287
6
Samuels-Kalow
ME
,
Stack
AM
,
Porter
SC
.
Effective discharge communication in the emergency department
.
Ann Emerg Med
.
2012
;
60
(
2
):
152
159
7
Curran
JA
,
Murphy
A
,
Burns
E
, et al
.
Essential content for discharge instructions in pediatric emergency care: a Delphi study
.
Pediatr Emerg Care
.
2018
;
34
(
5
):
339
343
8
Curran
JA
,
Bishop
A
,
Plint
A
, et al
.
Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol
.
BMC Health Serv Res
.
2017
;
17
(
1
):
276
9
Kaplan
HC
,
Provost
LP
,
Froehle
CM
,
Margolis
PA
.
The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement
.
BMJ Qual Saf
.
2012
;
21
(
1
):
13
20
10
Methodist Health System Emerging Leaders Cohort
.
Improving Patient Acknowledgement of Emergency Department Discharge Instructions at MRMC
.
2017
.
11
Pathman
DE
,
Konrad
TR
,
Freed
GL
,
Freeman
VA
,
Koch
GG
.
The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations
.
Med Care
.
1996
;
34
(
9
):
873
889
12
RLDatrix
.
Available at: https://www.rldatix.com/en-nam. Accessed September 14, 2022
13
Press-Ganey Associates, LLC
.
Available at: https://www.pressganey.com/. Accessed September 14, 2022
14
Provost
L
,
Murray
S
.
The health care data guide: learning from data for improvement
.
Available at: www.josseybass.com/go/provost. Accessed September 14, 2022
15
PQ Systems
.
16
Walsh
D
,
Gekle
R
,
Bramante
R
,
Decena
E
,
Raio
C
,
Levy
D
.
Emergency department sepsis huddles: achieving excellence for sepsis benchmarks in New York State
.
Am J Emerg Med
.
2020
;
38
(
2
):
222
224
17
Larson
LA
,
Finley
JL
,
Gross
TL
, et al
.
Using a potentially aggressive/violent patient huddle to improve health care safety
.
Jt Comm J Qual Patient Saf
.
2019
;
45
(
2
):
74
80
18
Fesnak
S
,
Abbadessa
MK
,
Hayes
K
, et al
.
Sepsis in complex patients in the emergency department: time to recognition and therapy in pediatric patients with high-risk conditions
.
Pediatr Emerg Care
.
2020
;
36
(
2
):
63
65
19
Hermanson
S
,
Osborn
S
,
Gordanier
C
,
Coates
E
,
Williams
B
,
Blackmore
C
.
Reduction of early inpatient transfers and rapid response team calls after implementation of an emergency department intake huddle process
.
BMJ Open Qual
.
2020
;
9
(
1
):
e000862
20
McBeth
CL
,
Durbin-Johnson
B
,
Siegel
EO
.
Interprofessional huddle: one children’s hospital’s approach to improving patient flow
.
Pediatr Nurs
.
43
(
2
):
71
76
21
Franklin
BJ
,
Gandhi
TK
,
Bates
DW
, et al
.
Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy
.
BMJ Qual Saf
.
2020
;
29
(
10
):
1
2
22
Borchard
A
,
Schwappach
DLB
,
Barbir
A
,
Bezzola
PR
.
A systematic review of the effectiveness compliance, and critical factors for implementation of safety checklists in surgery
.
Ann Surg
.
2012
;
256
(
6
):
925
933
23
Haynes
AB
,
Weiser
TG
,
Berry
WR
, et al.
Safe Surgery Saves Lives Study Group
.
A surgical safety checklist to reduce morbidity and mortality in a global population
.
N Engl J Med
.
2009
;
360
(
5
):
491
499
24
Pronovost
P
,
Needham
D
,
Berenholtz
S
, et al
.
An intervention to decrease catheter-related bloodstream infections in the ICU
.
N Engl J Med
.
2006
;
355
(
26
):
2725
2732
25
Catchpole
K
,
Russ
S
.
The problem with checklists
.
BMJ Qual & Saf
.
2015
;
24
(
9
):
545
549
26
Wu
S
,
Tyler
A
,
Logsdon
T
, et al
.
A quality improvement collaborative to improve the discharge process for hospitalized children
.
Pediatrics
.
2016
;
138
(
2
):
e20143604
27
Pritt
A
,
Johnson
A
,
Kahle
J
,
Preston
DL
,
Flesher
S
.
Better outcomes for hospitalized children through safe transitions: a quality improvement project
.
Pediatr Qual Saf
.
2020
;
6
(
1
):
e378
28
Auger
KA
,
Shah
SS
,
Tubbs-Cooley
HL
, et al.
Hospital-to-Home Outcomes Trial Study Group
.
Effects of a 1-time nurse-led telephone call after pediatric discharge: the H2O II randomized clinical trial
.
JAMA Pediatr
.
2018
;
172
(
9
):
e181482
29
Mallory
LA
,
Osorio
SN
,
Prato
BS
, et al.
IMPACT Pilot Study Group
.
Project IMPACT pilot report: feasibility of implementing a hospital-to-home transition bundle
.
Pediatrics
.
2017
;
139
(
3
):
e20154626
30
Uong
A
,
Philips
K
,
Hametz
P
, et al
.
SAFER care: improving caregiver comprehension of discharge instructions
.
Pediatrics
.
2021
;
147
(
4
):
e20200031
31
Boonyasai
R
,
Ijagbemi
OM
,
Pham
JC
, et al
.
Improving the Emergency Department Discharge Process: Environmental Scan Report
.
32
Vukovic
AA
,
Berry
C
,
Johnson
DP
.
A discharge vital sign documentation improvement initiative in the pediatric emergency department
.
Pediatrics
.
2019
;
144
(
3
):
e20190436
33
Murray
KA
,
Belanger
A
,
Devine
LT
,
Lane
A
,
Condren
ME
.
Emergency department discharge prescription errors in an academic medical center
.
Proc Bayl Univ Med Cent
.
2017
;
30
(
2
):
143
146
34
Cesarz
JL
,
Steffenhagen
AL
,
Svenson
J
,
Hamedani
AG
.
Emergency department discharge prescription interventions by emergency medicine pharmacists
.
Ann Emerg Med
.
2013
;
61
(
2
):
209
14.e1
35
Waehner
EN
,
Weightman
S
,
Castañeda
D
,
Morse
R
.
Discharge prescription errors after the implementation of a prospective pharmacist review process in a pediatric emergency department
.
Pediatr Emerg Care
.
2020
;
36
(
9
):
411
413
36
Martin
HA
,
Ciurzynski
SM
.
situation, background, assessment, and recommendation-guided huddles improve communication and teamwork in the emergency department
.
J Emerg Nurs
.
2015
;
41
(
6
):
484
488

Supplementary data