Sources of Non-Value Added Time in Emergency Department Care of Children with Moderate-Severe Traumatic Brain Injury
Ali Ajdari1, Richard A Farreth2, Omar Z Ahmed3, Nithya Kannan1, Linda Boyle1, *Monica S Vavilala1, *Randall S Burd, Jr.3
1University of Washington, Seattle, WA;2Childrrens Hospital DC, Washington DC, DC;3Childrens Hospital DC, Washington DC, DC
Purpose of Study: To examine the frequency and sources of non-value-added time (NVAT) during the initial management of children with moderate-severe traumatic brain injury (TBI).
Methods: Time-stamped data from a level 1 pediatric trauma center emergency department (ED) were reviewed. A process flow and value stream map for each patient was created; Sources of NVAT were identified and derived for each process flow.
Results: Thirty patients ranged in age from 0-16 years (mean 4.7, SD 3.7). The median ED Glasgow Coma Scale (GCS) score was 4 (IQR 2-5). The mean NVAT was 18.4 minutes (SD=99.7) and mean ED LOS was 38.4 min (SD 12.7). The portion of NVAT contributing to ED length of stay (LOS) was 38.6% (SD 14.0). Sixteen sources of NVAT grouped into four categories. The first three were: (1) waiting for test results (38%: head computer tomography scan, chest x-ray and blood work), (2) unidentified gaps between consecutive processes (20%), and (3) unexpected events (15%) due to difficult intravenous line placement, uncooperative patients, or unsuccessful blood draw). The fourth category, accounting for 26%, included sources of NVAT such as missing equipment, staff not being present, and waiting to be transferred.
Conclusion: Although ED LOS was under one hour, approximately 40% of ED LOS in moderate-severe TBI was NVAT. While unexpected events accounted for some proportion of NVAT, reducing time to results, appropriately resourcing ED care and further examining gaps in care offer opportunities to improve ED TBI care quality.
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