Pediatric Emergency Department Quality Improvement Blueprint

Quality Improvement is a systematic, data-driven approach to improving patient outcomes and systems of care.

The most widely used framework in healthcare comes from the Institute for Healthcare Improvement and centers on the Model for Improvement:

Aim → Measure → Change → PDSA → Measure → Refine → Spread

Core Components

• SMART Aim Statement: What are we trying to accomplish?
• Measures: How will we know a change is an improvement?
• Change Ideas: What can we test?
• PDSA Cycles: Plan → Do → Study → Act
  

For pediatric EDs, the most efficient way to begin is by selecting validated pediatric measures, ideally those already standardized nationally through NPRQI.

Every pediatric QI project should include three types of measures:

• Measure Type: Outcome – Purpose: Did patients do better?
• Measure Type: Process – Purpose: Did we reliably perform key steps?
• Measure Type: Balancing– Purpose: Did we unintentionally cause harm?

Why This Matters

Using nationally validated measures, such as those in NPRQI, ensures:

• Standard definitions
• Risk adjustment when applicable
• Benchmarking capability
• Alignment with pediatric readiness priorities

Sites not yet participating in NPRQI should align their internal definitions with NPRQI specifications whenever possible to allow future benchmarking and easier integration.

Example: Pediatric Sepsis

Outcome Measure

• Reduce risk-adjusted mortality for suspected pediatric sepsis from 4.2% to <2.5% by December 31, 2026.

Process Measure

• Increase antibiotics within 60 minutes from 52% to 90% by September 30, 2026.

Balancing Measure

• Maintain fluid overload requiring intervention at <5%.
• Together, these measures ensure improvement is meaningful, reliable, and safe.
• NPRQI includes standardized sepsis metrics that allow comparison across institutions while maintaining patient privacy through de-identified data submission.

Step 1: Establish Infrastructure

Essential components:

• Physician PECC
• Nurse PECC
• Data support (analyst or abstraction lead)
• Executive sponsor
• Frontline champions
• Clear reporting structure

Low-volume sites benefit significantly from collaborative benchmarking—something NPRQI participation uniquely provides.

Step 2: Start with Validated Measures

Preferred Approach: Lead with NPRQI Measures

NPRQI provides:

• Nationally validated pediatric ED measures
• Secure, de-identified data submission
• Risk-adjusted benchmarking
• Performance dashboards
• Alignment with pediatric readiness domains
  

Core Domains Include:

• Sepsis recognition and management
• Suicide risk screening
• Pediatric head trauma imaging
• Pain assessment and reassessment
• Transfer communication
• Equipment and medication safety
  

These measures are:

• Evidence-based
• Nationally standardized
• Designed for benchmarking
• Built specifically for emergency departments

If Not Participating in NPRQI

Sites should:

• Select measures aligned with NPRQI domains
• Use standardized definitions
• Track outcome, process, and balancing metrics
• Consider future enrollment to enable benchmarking
  

Participation enhances credibility, accelerates improvement, and reduces the burden of measure development.

Step 3: Additional Clinical-Based Measures

If expanding beyond core domains:

• Resuscitation
  • Time to epinephrine in anaphylaxis
  • Weight-based dosing accuracy
    
• Respiratory
  • Bronchiolitis guideline adherence
  • Asthma steroids within 60 minutes
    
• Trauma
  • CT use in minor head trauma (PECARN adherence)
    
• Medication Safety
  • Weight documented in kilograms
  • Independent double-check compliance
    

When feasible, align these metrics with national specifications to preserve benchmarking potential. Additional pediatric measures resources: PECARN

Regardless of participation status, all pediatric EDs should review:

• Pediatric deaths
• Intubations
• CPR events
• Sepsis with ICU admission
• ED deliveries
• Neonatal resuscitations
• Anaphylaxis requiring epinephrine
• Transfer to higher level of care within 24 hours
• Procedural sedation complications
• Medication dosing errors

These reviews should use:

• Structured review forms
• Root cause analysis when appropriate
• Learning-focused debriefs (not punitive)

Even for departments enrolled in NPRQI, structured case review remains essential for local systems learning.

Build a pediatric-specific dashboard to track measures, outcomes, and balancing metrics.

• Organize by domain, measure type, and key outcomes (e.g., sepsis process/outcome, pain reassessment, medication safety).
  
• Use visualization methods that fit your ED volume: run charts, control charts, compliance percentages, trend lines.
  
• Tip: NPRQI offers a secure, de-identified dashboard that allows benchmarking and structured performance tracking, which can supplement or guide your local QI tracking.

• Use NPRQI's secure platform to collect and benchmark pediatric QI measures whenever possible.
• If NPRQI participation isn’t feasible, use EMR reports, manual abstraction, or a hybrid approach to capture critical events and process measures.
• Sample all high-risk events; for high-volume EDs, consider random sampling for routine measures to balance workload and data quality.

Sampling Guidance

• Low volume ED: review 100% of eligible cases
• High volume ED: random monthly sampling
• High-risk events: always 100%

• Apply Plan-Do-Study-Act cycles to test changes in small, manageable steps before broader implementation.
• Use NPRQI measures to track improvement and refine interventions when available.
• If NPRQI isn’t used, apply the same PDSA methodology with local or validated measures to ensure structured improvement and safe care.

Example:

Aim: Increase antibiotic administration within 60 minutes for suspected sepsis from 45% to 80% in 6 months.

PDSA Cycle 1

• Plan: Add sepsis alert to triage workflow
• Do: Pilot on day shift for 2 weeks
• Study: Measure time to antibiotics
• Act: Refine criteria before scaling

Improvement requires transparency.

• Frontline Reporting
  • Monthly staff meetings
  • Visual dashboards in break room
  • Email infographics
  • Huddle updates
• Leadership Reporting
  • Quarterly executive summary
  • Highlight risk reduction
  • Align with strategic goals
• Individual Feedback
  • Peer comparison when appropriate
  • Non-punitive tone
  • Focus on system gaps, not blame

Participation in NPRQI strengthens leadership engagement by connecting improvement to recognized standards.

• Normalize case review
• Celebrate improvements
• Share “good catches”
• Use psychological safety language
• Close the feedback loop

National benchmarking through NPRQI reinforces psychological safety by framing performance in a broader context.

Quarter 1

• Sign up for NPRQI and explore available validated pediatric measures.
• If NPRQI participation isn’t possible, identify nationally validated measures or local benchmarks to use instead.
• Build your QI team, including physician PECC, nurse PECC, and other key champions.
• Begin planning your dashboard and reporting structure.

Quarter 2

• Launch 1–2 PDSA cycles using selected measures.
• Begin reviewing high-risk, low-frequency events (e.g., critical interventions, pediatric deaths).

Quarter 3

• Expand QI efforts to include medication safety and competency-based audits.
• Refine dashboards and reporting based on early results and feedback.

Quarter 4

• Evaluate overall performance and trends.
• Benchmark against national data if available (via NPRQI).
• Share findings internally and publish an annual summary to inform improvement and sustain progress.

• Tie measures to competency validation
• Align with pediatric readiness assessment
• Integrate into annual education
• Maintain participation in national benchmarking efforts

• Starts with validated national measures (NPRQI)
• Aligns with national standards
• Includes high-risk/low-frequency review
• Uses structured PDSA cycles
• Shares transparent data
• Focuses on systems improvements, not individuals
• Leverages national benchmarking whenever possible
• Closes the loop with frontline staff

While meaningful pediatric QI can begin locally, participation in NPRQI strengthens rigor, accelerates improvement, and connects EDs to a national community committed to improving emergency care for children.