Table 1

Plan-do-study-act (PDSA) cycles to test interventions for implementation of pediatric triage tool

Intervention 1Application of triage tool in different shifts.
PDSA 1 November 2015Test the application of the tool to one patient in the morning shift.As plannedPediatrician found the tool easy to use and it took him three minutes to fill the tool. Quantitative analysis for November 2015: Completeness - 32% correctness - 18%, appropriate care 16%.Based on the positive feedback decided to test the use of the tool in all - morning, evening and night shift.
PDSA 2 December 2015Spread the application of the tool to all shifts - morning, evening and night shift.As plannedQualitative analysis - Tool was valued for its role and was easy to use. However, interviews revealed the need of additional nursing staff in the evening and night shift. Quantitative analysis for December 2015 : Completeness - 41%, correctness -17%, appropriate care - 17%.Action : (1) Retain tool introduction to all shifts (2) add additional nursing manpower (3) review reasons for improper application and seek ideas to address any barriers.
Interim review: The team met to identify possible barriers and brainstorm ideas to support the use of the tool. The following themes emerged in the review - (a) Pediatricians suggested that regular feedback regarding their tool application would be helpful. (b) They also shared that they were forgetting to fill the tool and would need regular reminders in the initial stages of implementation. (c) They also mentioned that the tool was added documentation and would be hard to fill during busy times. The team decided to address the concerns raised by the pediatricians and came up with change ideas to resolve them. The following PDSA cycles were thus initiated sequentially to test these change ideas.
Intervention 2Testing daily huddles to give feedback to pediatricians.
PDSA 3 January 2016Testing daily huddles to give feedback to pediatricians on errors in triage tool application.As plannedQualitative: Pediatricians appeared comfortable with receiving feedback about their errors. Quantitative - Complete entries increased to 76%, correctly entries increased to 55%. Appropriate care improved to 48%.Change idea appeared successful and hence intervention retained. Decided to test the idea for the next month with another PDSA.
PDSA 4 February 2016Testing daily huddles to give feedback to pediatricians on errors in triage tool application for another month.As plannedQualitative: Pediatricians resented getting feedback and perceived it as a criticism of their performance. Quantitative: Appropriate care fell to 33%. Completeness of tool - 62% and correctness 36%.Intervention not resulting in desired outcomes hence rejected the change.
Intervention 3Testing nurse led reminders to pediatricians.
PDSA 5 March 2016Using nurse led reminders to pediatricians for filling the triage tool completely.As plannedQualitative - senior nurses comfort with reminders while junior nurses hesitated due to prevailing hierarchical dynamics. Pediatricians subsequently did not like being reminded. Quantitatively- appropriate care remained unchanged (36%).Intervention not considered useful hence rejected.
Intervention 4Testing simplification of clinical health record.
PDSA 6 April 2016Simplification of clinical health record to create time for tool application.As plannedThe team highly valued the time saved for clinical interactions over paper work. However, appropriate care remained at 36% with tool completeness at 69% and correctness at 39%.Though this change did not improve appropriate care we retained the simplified record as it saved time which could be judiciously used for clinical interactions.
Interim review: We reached out to all pediatricians individually. Some pediatricians expressed challenge of a heavy load in the ward which amounted to rushed application of tool. Clash between prioritizing triage documentation over clinical attention to the child and their anxious family was another cited reason. We spent April and May exploring an idea of engaging the RMOs on using the triage tool at times when the pediatrician was busy. We decided to test this intervention through a PDSA in June 2016.
Intervention 5Testing feasibility and effectiveness of engaging RMOs for tool application.
PDSA 7 June 2016Feasibility and effectiveness of engaging RMOs for tool application during a busy pediatrician work shift for uninterrupted tool use.As plannedThe RMOs, nurses and pediatricians all resented this change. The RMOs felt less capable and confident than the pediatricians in assessing children correctly and nurses shared that parents wanted the pediatricians to see their children. Pediatricians perceived that RMO’s telephonic dependency on a pediatric consult did not relieve any burden during busy times. Quantitatively : completeness, correctness, and appropriate care, all decreased to 54%, 31% and 27% respectively.Change idea could not add value to increasing tool usage to all consults - was rejected.
Interim review: July and August witnessed a further drop in appropriate care to 20% and 19% respectively. We found that the number of pediatric patients coming to the emergency increased more than twofold during these months due to seasonal infections. The nursing team observed delays in supply of stationary and late recruitment of additional manpower. Any administrative changes like change in staff duties, ordering medicines, consumables or even ordering stationary in the emergency required approval of the nursing and pediatric department causing unnecessary delays in day to day management. This led us to transition to model of local leadership for emergency care delivery. We tested the idea of local leadership with this PDSA.
Intervention 6Promoting an early adopter to a triaging supervisor, a senior nurse to coordinate all triage related requirements and implementations.
PDSA 8 September 2016Promoting an early adopter to a triaging supervisor, a senior nurse to coordinate all triage related requirements and implementations. She was authorized to take administrative decisions related to the same.As plannedDesignated supervisor was highly valued as it improved work efficiency and helped in promptly addressing hurdles. Quantitatively data unveiled improvement with complete entries for 70% and correctly entries for 46% of the patients leading to 43% appropriate care.This intervention appeared to be well received hence retained.
Intervention 7Retaining the triaging supervisor to coordinate all triage related requirements and create a pool of select locum pediatricians.
PDSA 9 October 2016Retaining the triaging supervisor to coordinate all triage related requirements and create a pool of select locum pediatricians.As plannedIncreased engagement of team by supervisor and regular training of the locums was well accepted by the team. Quantitatively - For October and November appropriate care was 44% and 42% respectively.Team leadership and stable team helped achieve improvement in transforming practice to incorporate tool application as desired.