Standardized workflow improves outcomes in children admitted for abdominal pain

A quality improvement (QI) project consisting of a standardized management workflow with stringent discharge criteria for paediatric abdominal pain admissions at KK Women’s and Children’s Hospital in Singapore has resulted in reduced length of stay (LOS), number of unnecessary investigations, and variability in investigations ordered, without causing misdiagnosis, reports a study.

“It improved patient experience with sizeable cost savings for the patient and the hospital,” the researchers said. “QI projects can improve patient outcomes by introducing standard protocols that aid clinical management.”

Most patients (61 percent) admitted to the Department of Pediatric Surgery (PAS) presented with nonsurgical abdominal pain throughout three Plan-Do-Study-Act (PDSA) cycles conducted. [Proc Singap Healthc 2023;doi:10.1177/20101058231188875]

In the third PDSA cycle, compliance to workflow improved (80.7 percent) with reduced median LOS by 1 day; reduced median number of blood, stool, and urine investigations by 1; and reduced range of investigations ordered.

In addition, the rate of readmission and children’s emergency attendance 1 week after discharge was 1.6 percent (n=1). This was similar to audit, which had a rate of 2.3 percent (n=4; p=0.709).

“Our standardized workflow improved LOS and reduced unnecessary investigations by reducing variation in clinical practice without introducing patient morbidity,” the researchers said. “The workflow guided inexperienced junior doctors faced with clinical uncertainty to make decisions and helped them rely less on unnecessary investigations.”

Participation in QI activities allowed clinicians to make changes in their healthcare system, which led to improved care for their patients. [BMJ 2020;368:m865]

Apart from shorter hospital stay and fewer tests, patients also spent less, with cost savings for reduced number of investigations ordered (from five to four) and reduced LOS (from 2 days to 1) of about SGD 678 per patient, at hospital full charges rate in 2022. Given the hospital average of 2,016 patients per year admitted to PAS due to nonsurgical/nonurgent abdominal pain, this translated to annual cost savings of nearly SGD 1,366,848.

“Due to our public hospital setting with partially subsidized healthcare, this results in sizeable taxpayer savings,” the researchers noted.

Challenges

One of the challenges encountered by the QI team was frequent rotation changes of junior doctors, which affected compliance to the workflow, because briefing sessions had to be adjusted to accommodate work schedules. Another challenge was documentation by junior doctors, which affected data collection about compliance. To address the incomplete documentation, triangulation with other electronic medical records and timestamping of investigation orders were performed.

Notably, support of the stakeholders was necessary at all QI stages. Prior to implementation, some PAS seniors expressed their concern about missing surgical diagnoses with the proposed management algorithm. In response, the researchers created more safeguards of strict discharge criteria, return advice brochures for caregivers, and simplified patient access to get early outpatient PAS reviews. [BMJ 2020;368:m865]

“The QI audit confirmed that no patient had delayed diagnosis nor was readmitted for surgical condition within 1 week after their initial hospitalization discharge,” the researchers said. “This has reaffirmed departmental support for this workflow.”

In this study, the research team reviewed the outcome measures of LOS, number of investigations ordered, compliance to workflow, and readmission within 1 week following discharge at the end of each PDSA cycle. They improved workflow by following the QI principles.