Pediatric Emergency Department Quality Improvement Blueprint

QI is a data-driven approach to improving patient care and associated outcomes. More specifically, from the lens of Pediatric Readiness, QI is focused on improving pediatric emergency care (i.e., care processes that directly impact patients).

As a foundational first step, EDs should establish a process to regularly review pediatric patient deaths and high-risk transfers to identify opportunities for improvement. For EDs without an existing review structure, begin by partnering with your local quality department (if one exists) to define cases for review, assign clear ownership (e.g., physician and nurse champions), and implement a simple, recurring case review process. Adopting a continuous QI framework can then build on this foundation and meaningfully improve pediatric emergency care and outcomes in your ED.

The most widely used framework for continuous QI in healthcare comes from the Institute for Healthcare Improvement (IHI) and centers on the Model for Improvement:

Core Components

• Aim Statement: What are we trying to accomplish?
• Measures: How will we know a change is an improvement?
• Change Strategies: What system changes can we implement to improve care?
• Monitoring PDSA Cycles: Plan → Do → Study → Act
  

For QI in EDs related to pediatric care, the most efficient way to begin is by selecting relevant, meaningful, and actionable pediatric measures, ideally those already nationally vetted.

Every QI project requires a team. Before beginning, identify who will support the work. If your organization has an established QI structure, partner with your local QI team (if one exists) and align with current processes. If not, intentionally build a small, interdisciplinary team to lead the effort. Securing buy-in from both leadership and frontline care team members is essential to success.

Consider how you will oversee and manage your QI effort. Some potential team members include:

• Physician PECC
• Nurse PECC
• Data support (data abstraction and tracking)
• Leadership support (ED and/or hospital administration)
• Other healthcare providers (nurses, physicians, APPs, etc.)
• QI specialist from your hospital, if available

More complex projects may require additional team members (e.g. pharmacist). Establish a regular communication and reporting plan. Also, settle on a meeting cadence to ensure the project progresses well and that you have the resources and support to improve care effectively.

Decide whether your site is interested and able to participate in the National Pediatric Readiness Quality Improvement (NPRQI) data platform:

• Sign up for the NPRQI data platform and explore NPRP measures and clinical areas of focus.
• If NPRQI participation isn’t possible, explore NPRP measures and identify nationally validated measures or local benchmarks to use instead.

High-risk, low-frequency pediatric events (e.g., cardiac arrest, severe sepsis, major trauma, and airway compromise) occur infrequently in most EDs, yet carry significant potential for morbidity and mortality. Because these events are uncommon, teams may have limited real-time exposure, making structured review essential to ensure clinical competence, system readiness, and optimal patient outcomes.

Despite ongoing QI initiatives, every ED should establish a standardized, recurring process to review high-risk, low-frequency pediatric events. Reviewing these cases provides an opportunity to evaluate overall ED performance, including recognition, escalation, resuscitation, teamwork, equipment readiness, and disposition processes, before moving to condition-specific performance measures. Regular review strengthens systems of care, identifies latent safety threats, reinforces best practices, and supports team performance in rare but critical scenarios.

At a minimum, this process should include:

• Pediatric deaths
• Resuscitations, including neonatal
• ICU admissions
• Emergent transfers out
• Medication dosing errors

Additional considerations include:

• Child births/neonatal deliveries in the ED deliveries
• Anaphylaxis
• Procedural sedations

Start with nationally accepted, evidence-based measures such as those listed in the 2026 joint policy statement, Pediatric Readiness in the Emergency Department (NPRP measures).

Preferred Approach: Lead with  NPRQI data platform.

NPRQI data platform provides:

• Nationally vetted, standardized pediatric measures
• Secure, confidential data transformation portal
• Benchmarking against national cohorts and similar EDs
• Performance dashboards

Clinical Care Bundles Include:

• Patient assessment and reassessment, including pain
• Interfacility transfers
• Blunt head trauma
• Seizures
• Respiratory distress
• Vomiting and dehydration
• Suicide risk screening and management
• These measures are:
  • Evidence-based
  • Nationally vetted and standardized
  • Prioritized specifically for emergency departments, including low-volume EDs

If Not Participating in NPRQI, sites should:

• Select evidence-based pediatric quality measures that are relevant and meaningful for the pediatric population seen in your ED
• Establish baseline performance by collecting initial performance data over a set period of time (e.g., quarter)
• Identify opportunities for improvement based on baseline data
• Initiate cycles of improvement and track performance on chosen measures over time
• Consider future enrollment to enable benchmarking with national cohorts

Participation in NPRQI provides the technical infrastructure needed to accelerate improvement, reduces the burden of measure development, and allows for benchmarking with similar sites.

Quality measures typically focus on adherence to standardized processes of care or improvement in patient-centered outcomes. Every QI project should begin with at least one quality measure focused on pediatric emergency care.

Process measures focus on one or more steps in the clinical care process. The purpose – did we reliably perform key steps?

Outcome measures focus on patient-centered outcomes. The purpose – did patients have a better outcome?

• Regardless of what measure is chosen, it should ensure improvement is meaningful, leading to improved outcomes for patients

Using nationally vetted measures, such as the NPRP measures, ensures:

• Standard definitions
• Evidence-based
• Benchmarking against similar ED cohorts available via the NPRQI data platform
• Focus on common pediatric presentations that are actionable even among community and low-volume EDs.

Example: Pediatric Asthma

Outcome Measure

• ED length of stay for pediatric patients with an asthma exacerbation.

Process Measure

• Percent of pediatric patients with an asthma exacerbation who receive steroids

A global aim describes what you are trying to accomplish. Examples might include improving pain assessment and management in pediatric patients or increasing adherence to asthma standards of care among pediatric patients.

Once you have a global aim, it is important to consider how you will know if improvement occurs. In other words, what will you measure to demonstrate improvement through data?

Baseline performance data should be obtained once you have selected one or more measures that reflect the quality of pediatric emergency care relative to your clinical area of interest and align with your global aim. Pediatric patient encounters should be reviewed to understand how your site is currently performing with respect to the clinical area of interest. Specifically, the elements defined in your selected quality measures (e.g., administration of steroids) should be collected and tallied.

If your site chooses to participate in NPRQI, the data is automatically transformed into performance measure calculations for your site. If NPRQI participation isn’t feasible, use electronic medical record (EMR) reports, manual abstraction, or a hybrid approach to capture critical events and process measures.

The period over which baseline data is collected may vary and depends, in part, on the volume of pediatric patients seen. The frequency of exposure to the condition of interest is important to ensuring the baseline data adequately reflects average performance. Baseline data should be collected until the overall performance on the measures of interest appears relatively stable.

Choosing the correct patient cohort:

If focusing on pediatric patient assessment, then all pediatric patients who present to the ED may be included in your performance review. However, if your clinical focus is head trauma, then only pediatric patients who suffered head trauma should be included in your baseline data collection. Even so, for higher-volume centers, reviewing every pediatric patient encounter for a given clinical condition may not be feasible. In this case, a systematic data sampling strategy whereby every Nth patient is selected is appropriate.

Regardless of the data sampling strategy chosen, baseline performance data is essential to developing a SMART aim to guide your improvement efforts.

Once baseline data is obtained and performance reviewed, a SMART aim should be drafted. SMART aims set the goal for your project.

S = Specific, the aim statement should clearly state the goal

M = Measurable, the goal should be quantifiable

A = Achievable, the goal should be within reach based on the current performance

R = Relevant, the goal should be relevant to pediatric emergency care and the specific clinical area of focus

T = Time-bound, a set time point at which the goal should be achieved is defined

Example: Over the next 12 months, we will increase the percent of pediatric patients who present to the ED with acute asthma who receive steroids from a baseline of 60% to 80%.

Once a SMART aim is established and the team agrees, the next step is deciding what actions might lead to improvements in system performance. Thus begin your first Plan-Do-Study-Act cycle.

• Use the Model for Improvement template to initiate your proposed project, then apply Plan-Do-Study-Act (PDSA) cycles to test changes in small, manageable steps before broader implementation.
• Start with NPRP measures to track improvement and refine interventions when available
• Regardless of whether a data platform is used to support your work, apply the same PDSA methodology with local or validated measures to ensure structured improvement and safe care.

Example:

Aim: Increase the proportion of pediatric patients with a documented pain score.

PDSA Cycle 1:

• Plan: Post a pediatric pain assessment tool in the triage rooms
• Do: Pilot for 2 weeks
• Study: Measure the percent of pediatric patients with pain assessed
• Act: Consider additional refinements or strategies based on performance

NPRQI Data Platform

Use of a secure data platform strengthens pediatric quality improvement efforts by connecting local work to recognized standards and enabling structured performance tracking. Participation in the NPRQI provides access to a secure, confidential dashboard designed specifically to support pediatric emergency care improvement.

NPRQI participation offers:

• Nationally vetted, standardized pediatric measures
• A secure and confidential data submission and transformation portal
• Benchmarking against national cohorts and similar EDs
• Performance dashboards with structured reporting
• Access to clinical care bundles, including:
  • Patient assessment and reassessment (including pain)
  • Interfacility transfers
  • Suicide risk screening and management
  • Pediatric head trauma assessment and management
  • Pediatric respiratory distress
  • Vomiting and dehydration
  • Pediatric seizure management

Participation strengthens leadership engagement, reduces the burden of developing measures internally, accelerates improvement, and connects EDs to a national community focused on improving emergency care for children. For low-volume sites in particular, benchmarking against peer institutions provides valuable context when national standards may not otherwise exist.

Building a Pediatric Dashboard (If Not Using NPRQI)

If your ED is not participating in NPRQI, develop a pediatric-specific dashboard to track performance and share results with frontline teams and leadership.

Key steps to establish a dashboard:

• Define Priority Clinical Focus Areas (See examples below)
  • Sepsis (process and outcomes)
  • Pain assessment and reassessment
  • Medication safety and weight-based dosing accuracy
  • Airway management
  • Interfacility transfers
  • Mental health screening
• Select Clear, Operationalized Measures
  • Define numerator and denominator
  • Standardize inclusion/exclusion criteria
  • Align with published pediatric readiness measures when possible
  • Process measures should be derived from evidence-based clinical algorithms
• Organize Data Logically
  • By clinical focus area
  • By process vs. outcome measure
  • By performance over time
• Use Simple Visualization Methods
  • Run charts
  • Control charts (if resources allow)
  • Compliance percentages
  • Trend lines over time
• Establish a Reporting Cadence
  • Monthly or quarterly review
  • Multidisciplinary review meetings
  • Leadership reporting structure
  • Closed-loop feedback to frontline staff
• Integrate into Quality Infrastructure
  • Draw connections to HRLF case reviews
  • Include in PECC or pediatric champion meetings
  • Incorporate into annual Pediatric Readiness planning

Even without participation in a national platform, a structured dashboard promotes transparency, reinforces accountability, and helps ED teams identify trends, gaps, and opportunities for improvement. Aligning with standardized NPRP measures will allow for easier transition to national benchmarking platforms if desired.

Improvement requires transparency. It is also important to communicate the impact of your work to demonstrate value.

• Frontline Reporting
  • Monthly staff meetings
  • Visual dashboards in the breakroom (where all staff can view)
  • Whiteboard in ED hallway
  • Email infographics
  • Daily huddles
• Leadership Reporting
  • Quarterly executive summary
  • Highlight risk reduction
  • Align with strategic goals

Structured case review processes directly support the safety pillar of QI by identifying system vulnerabilities, reducing risk, and preventing future harm.

Core Review Practices

• Use structured review forms to ensure consistent, objective case evaluation
• Conduct root cause analysis when appropriate to identify contributing system factors
• Facilitate learning-focused, data-driven debriefs that emphasize improvement—not blame

Culture & Sustainability

• Normalize routine case review as standard practice
• Celebrate improvements and measurable progress
• Share “good catches” to reinforce harm prevention
• Use psychologically safe, non-punitive language
• Close the feedback loop so teams see how their input drives change

If your ED is performing well on all of the NPRP measures, consider more advanced clinical quality measures.

Consider evaluating for variability in care:

• Track and assess for differences in performance by patient age category, payor source, triage level, or other demographic factors.

Consider other common or high-risk pediatric presentations:

• Time to epinephrine in anaphylaxis
• Time to blood product administration in multi-system trauma
• Reduce use of CT imaging for diagnosis of appendicitis
• Medication dosing errors
• Time to antibiotic administration in suspected sepsis

Many other pediatric quality measures exist in the scientific literature based on standardized evidence-based clinical guidelines. When selecting new measures for adoption, lean towards nationally vetted or endorsed measures.

Regional children’s hospitals and/or tertiary care centers might suggest other pediatric emergency care measures that would support regional collaboration for improvement.

Quarter 1

• Build your QI team, including physician PECC, nurse PECC, and other key champions, such as quality team members
• Explore NPRP measures or identify nationally validated measures or local benchmarks to use.
• Begin planning your dashboard and reporting structure

Quarter 2

• Decide on an area of focus
• Collect baseline performance data
• Create a SMART aim
• Begin reviewing high-risk, low-frequency events (e.g., pediatric deaths; resuscitations, including neonatal)

Quarter 3

• Launch 1–2 PDSA cycles using selected measures.
• Refine dashboards and reporting based on early results and feedback.

Quarter 4

• Evaluate overall performance and trends.
• Continue PDSA cycles to drive improvements and achieve SMART aim
• Benchmark against national data, if available (via the NPRQI data platform).
• Share findings internally and publish an annual summary to inform improvement and sustain progress.
• Expand QI efforts based on initial successes

• Start with NPRP measures
• Review high-risk/low-frequency events
• Use structured PDSA cycles
• Integrate QI program overview into annual staff education
• Communicate impacts to leadership
• Focus on systems improvements, not individuals
• Close the loop with frontline staff
• Join NPRQI to leverage national benchmarking and facilitate data visualization