January 2024 Newsletter

NEW YEAR- New Changes

2023 - edit

Happy New Year! As we step into 2024, we are filled with excitement and anticipation for the opportunities that lie ahead. This January, we’re not just celebrating the turning of the calendar but also the progress being made for pediatric readiness as part of the Pediatric Readiness Quality Improvement Collaborative.

Lets take a moment to acknowledge and celebrate the milestones we achieved together over the past year. Your dedication and hard work have laid a strong foundation for the journey that awaits us.

As we embrace the fresh start, we are excited to learn more about the change strategies that our participating sites are embarking on. Change strategies will vary from site to site depending on support and existing structure. These changes can be centered around the following areas: policies/procedures, EMR optimization, educational offerings, knowledge-reinforcement strategies, or patient-centered strategies.

Hear from peers about current change strategies at their sites


  • Addition of pain to vital signs forms the ED techs complete
  • Audit pediatric patient (age 14 and less) charts for improvement in vital sign documentation
  • Monthly data updates
  • Also adopted official evidence-based pain scales for each age group of patients

EMR Optimization

  • Placed a hard stop on EHR notes to force a pain assessment at triage
  • Adding a question to the RN screener form to ask about actual or thoughts of harming self
  • Implementing the Stoplight pain scale in the EMR


  • Educating staff around obtaining a full set of vital signs at triage then after intervention and prior to discharge
  • Staff education disseminated in multiple formats
  • Re-education of staff on full set of vital signs upon arrival and according to ESI level, including temperature, mental status, and pain assessment
  • Education via staff meetings, shift briefings, EM


  • Having normal vital sign charts in triage
  • Badge buddies with pain scale visual aids for nursing staff; visibility board in the ED with pain scale info
  • Posters in the breakroom and ED nursing stations

Patient-Centered Strategies

  • Visual aids for pain scales in every room
  • Posters in each patient room with the FACES pain scale

Learn more about current QI projects from participating sites

  • Pediatric patients have age-appropriate pain scale documented during ED visit
  • To increase percentage of pediatric patients with initial pain assessment
  • More accurately address pediatric pain by completing developmentally appropriate pain assessments for all pediatric patients, ages: 0 - 14 y/o,at the time of arrival, and re-assess within 1 hour of an intervention
  • Automated alert in EMR as reminder to use CSSRS for suicide screening, triage RN be able to perform universal screening to all patients aging 10-14 years old and targeting screening to all patients 5-9 years old
  • To meet best practice standards ED staff will be re-educated on obtaining a blood pressure on all pediatric patients, ages: 0 - 14 y/o at least once during their ED visit; and that a B/P at discharge is mandatory on all transfers, regardless of age, to another facility
  • Increase vital sign re-assessment
  • Pediatric pts will have a BP with HR, RR, and O2 sat within 30 min of departure charted
  • Care team be able to reassess pain 30 mins after IV administration and 60 mins after oral medication

Make sure to have:

  • Completed the environmental scan
  • Developed an implementation plan
  • Identified a clinical area of focus
  • Entered 25-30 patient encounters for baseline data- 2023 data entry closes on January 30, 2024

Please make every effort to complete baseline data entry to ensure your site keeps pace with the collaborative and completes 3-4 PDSA cycles by December 2024. By working through at least 3-4 PDSA cycles, your site will develop and implement strategies that ensure the sustainability of your efforts, ultimately leading to improvements that will surpass the initial performance achieved in the first few PDSA cycles.

Issues accessing the NPRQI data portal?

If you have received your secure login credentials and still having issues with accessing the NPRQI data portal, please email Clario Support Team. If you need to add or remove users, please email liza.hinojosa@austin.utexas.edu.

Register today for the Jan. 16 PRQC session