In 2022, pediatric urology surgeons in the University of Colorado Department of Surgery started to note an alarming trend: The number of young patients and their families who were returning to the emergency department (ED) after a urologic surgery such as a circumcision or a hernia repair was on the rise.
“For some of them, it was completely unrelated to surgery, which obviously we don't have control over,” says Kelly Harris, MD, assistant professor of urology. “But when it was related to surgery, we were finding a significant portion of children who were coming to the ED and were discharged just with reassurance. They often were having a very long ED stay — and the cost of an ED visit as well — that could have been avoided with either a phone call, sending us a picture, or a quick clinic visit.”
A plan to help
Harris and her colleagues began work on a protocol to reduce the number of unnecessary postoperative ED visits within 30 days — a plan Harris and her team presented at the Pediatric Urology Fall Congress in Louisville, Kentucky, in September.
“When you have a problem like this, it’s easy to say, ‘The parents need to do better; the surgeons need to do better,’” she says. “But from a quality improvement standpoint, we tried to look at it more globally and see if there was anything we could do to make this problem improve.”
That included changing discharge instructions to stress to families that there is a phone number they can call, 24-7, to reach a live person with any question about a procedure or its aftereffects. Space was created in the clinic for same-day or next-day appointments to evaluate urgent concerns.
The new protocol also includes a decision tree for the nurses who answer the phone line, helping them decide, based on symptoms, who should come to the clinic, who can go to urgent care, and who should go to the ED. For those who are routed to the ED, providers can help prepare the ED staff for their arrival.
“That eliminated some of the mental load of deciding whether or not people need to come to the ED,” Harris says. “It made it very clear about who was a definite, ‘Yes, they need to come in,’ or who could do a next-day clinic visit. That was a nice way to utilize the system to help patients stay out of the ED. If we created that space in the clinic, then we could see patients in a much easier setting, both for the families and for us as providers.”
Addressing multiple factors
A few extra ED visits may not sound like that big of a deal, but the problem has effects across the board, Harris says.
“It's multifactorial — from the emergency room perspective, this saves a bed for someone who needs it, something that is truly emergent,” she says. “From a hospital standpoint and the patient standpoint, it is cost-saving, but there's also a lot of emotional cost that comes with an ED visit. When you sit in the waiting room with other sick people for potentially seven or eight hours, just to be told that everything looks normal, it can be very frustrating.”
The numbers spell success
Six months after implementing the new quality improvement protocol, the pediatric surgery group saw its median inappropriate 30-day ED return rate sink to 2.2%, a 48.8% decrease from the baseline. Future iterations of the system will continue to reinforce triage protocols while tracking the proportion of patients who successfully utilized urgent clinic visits for postoperative concerns.
The success is encouraging to Harris, who says supporting children and their families is at the heart of all pediatric surgery.
“The general thing I always tell families is that I do not want any mom, dad, or caregiver at home, worrying by themselves,” she says. “If they are concerned about anything or have a question, they will always have a phone number to call. The more we can emphasize our willingness to be available to families, the more they will utilize that. That's what has really made a difference in keeping the momentum going and keeping our numbers more in line with what we would expect or hope.”
