General Pediatric Clinic Research Articles

Differences in self-reported weekend catch up sleep between children and adolescents with and without primary hypertension

BackgroundThe data on the association of sleep duration and blood pressure in the pediatric age group have been mixed and most studies have focused on weekday sleep duration. The purpose of this study was to compare the weekday and weekend sleep patterns between children and adolescents with newly diagnosed primary hypertension and a normotensive control group.MethodsChildren and adolescents from a pediatric nephrology clinic, aged 6-18 years with newly diagnosed primary hypertension were compared to an age and sex matched normotensive control group from a general pediatric clinic. The questions about bed time and getting out of bed times from the Pediatric Sleep Questionnaire (PSQ) were used to obtain weekday and weekend bed time, getting out of bed time and sleep duration. The Pediatric Daytime Sleepiness Scale (PDSS) was used to assess subjective sleepiness.ResultsIn both groups of 60 subjects each, weekday total sleep time was similar. Subjects in both groups went to bed later and woke up later on the weekends. However, in the hypertensive group, weekend getting out of the bed time was earlier (8:52 AM ±93 min vs. 9:36 AM ±88 min, p = 0.013) and weekend catchup sleep was about 40 min less (62.8 ± 85.5 vs. 102.7 ± 84.9, p = 0.035). Hypertensive children perceived less subjective sleepiness (PDSS scores 8.28 ± 4.88 vs. 10.63 ± 5.41, p = 0.007). The p values were calculated after adjusting for body mass index (BMI), race, daytime nap, caffeine use, sleep related breathing disorder (SRBD) scale and periodic limb movement of sleep (PLMS) scale subcomponents of the PSQ.ConclusionsHypertensive children obtained less weekend catch up sleep and reported less subjective sleepiness compared to the control group. More weekend sleep may potentially mitigate the effect of weekday sleep deprivation on blood pressure.

Knowledge and practice of parents and guardians about childhood asthma at King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia.

BackgroundFamily management of asthmatic children is affected by several factors, primarily the parent’s knowledge and attitude toward asthma.ObjectiveThe aim of this study was to explore the knowledge and practice of parents and guardians about asthma in their children.MethodsTwo hundred and thirty-one self-administered questionnaires were distributed to parents and guardians attending, with their children, general pediatric and pediatric pulmonology outpatient clinics at King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia, during the period from August 2016 to March 2017.ResultsMost of the participants (79.6%) have moderate knowledge. The mean of total knowledge was found to be higher among mothers compared with other groups (p=0.019). Most participants (88.3%) reported providing asthma treatment regularly and 61.9% visited the clinic regularly. Almost half of the participants have misconceptions about asthma medications. During acute asthma attacks, more than half of the participants (54.5%) massaged their child’s chest or back, and 52.4% provided the child homemade or herbal remedies.ConclusionThis study revealed a moderate level of knowledge about asthma among the parents and guardians of asthmatic children, but poor knowledge about asthma medications. For better control of asthma, more effort is needed to educate caregivers and to enhance their awareness about asthma and highlight the misconceptions about asthma medications at both hospital level and community level.

Parental awareness of testicular torsion amongst Irish parents.

Testicular torsion is the most concerning underlying cause of acute scrotal pain that can lead to loss of the affected testicle. Whether a torted testicle can be salvaged surgically is directly affected by prompt presentation and diagnosis. This study aims to evaluate the awareness of testicular torsion amongst Irish parents and evaluate their response to a potential torsion. An anonymous questionnaire was distributed to parents attending general paediatric clinics and an acute paediatric unit in two paediatric tertiary referral centres. SPSS statistical analysis software was used to perform multivariant analysis of the data. There were 242 completed surveys. Fifty-six percent of responders had an awareness of torsion. In the event of an episode of severe testicular pain parents who were aware of testicular torsion were 4 times more likely to present immediately than those who had no awareness of torsion (OR 4.2, 95% CI1.4-12.2, P < 0.01), and those who identified correctly the critical timeframe were 3 times more likely to present immediately than those who did not (OR 3.0, 95% CI 0.85-10.8, P = 0.08). Of those parents with boys only 11% had discussed what to do in the event of acute scrotal pain. Education of this topic to the general Irish population and in particular to parents and young males is not established. Both knowledge of testicular torsion and awareness of the urgency in presentation are factors that determine parents promptness in seeking medical attention for their child in the setting of acute scrotal pain.

Pediatric and Gynecologic Rates of Documentation of Last Menstrual Period in Female Adolescents.

The American Academy of Pediatrics and American College of Obstetricians and Gynecologists have identified the menstrual cycle as essential in assessing overall health of adolescent girls. Menses should be considered a "vital sign" and documentation of last menstrual period (LMP) is recommended at every patient encounter. The aim of this study was to estimate and compare LMP documentation among adolescent and pediatric health care providers. A retrospective cohort study identified a random sample of 50 female patients seen in the general pediatrics (PEDS), adolescent medicine (AM), and pediatric and adolescent gynecology (PAG) ambulatory clinics at Phoenix Children's Hospital between January 1, 2016 and March 31,2016. Rates of LMP documentation were compared between clinics using the Pearson χ2 test. Multivariable logistic regression analyses quantified the association of clinic and LMP documentation, with adjustments for visit reason, provider gender, and age at presentation. Rates of LMP documentation were 100%for adolescent gynecologists, but significantly lower for general pediatricians (14%) and AM (60%) providers (P<.0001). These findings were confirmed in multivariable analyses (PAG vs PEDS: odds ratio [OR], 280; 95% confidence interval [CI], 32-2331; PAG vs AM: OR, 34; 95% CI, 4.4-270; AM vs PEDS: OR, 3.8; 95% CI, 1.3-11.0). Adolescent gynecologists document LMP routinely. In contrast, LMP documentation rates in AM, and especially in PEDS, were significantly lower. Quality improvement methods such as incorporation of an LMP section into the vitals portion of an electronic medical record could help improve rates of compliance.

Characteristics of Correctly Identified Pediatric Obesity and Overweight Status and Management in an Academic General Pediatric Clinic.

This study identified and characterized the rates of documentation and guideline-based management of overweight and obese children within an academic pediatric clinic through a retrospective electronic medical record review of 7422 well-child visits in 2016. Diagnosis and treatment were analyzed by patient's weight diagnosis, sex, age, and provider training level. The percentages of correctly identified severely obese (90.2%), obese (77.0%), and overweight (42.0%) children were much higher than in previous retrospective chart reviews; however, less than 30% of children were referred for more intensive weight management to a dietitian or pediatric obesity weight management program. Increased provider training level was associated with a lower adherence to pediatric obesity guidelines. Strategic modifications to electronic medical records that automatically offer body mass index-associated weight diagnoses with a link to treatment pathways and resources are needed to facilitate improved compliance with current pediatric obesity guidelines in the primary care setting.

Pharmacist-managed short-acting beta agonist refill service in a general pediatric clinic

ObjectivesTo use a pharmacist-managed short-acting beta agonist (SABA) service (1) to determine the patient’s rationale for SABA refill requests, (2) to assess adherence to current controller therapy and current level of disease control, and (3) to characterize the pharmacist’s recommendations made in response to a patient’s SABA refill request. SettingAn academic-based general pediatric clinic. Practice DescriptionSABA overuse is a marker of increased morbidity and mortality in children with asthma. This article describes a pharmacist-managed SABA refill telephone service. Practice InnovationThe pediatric ambulatory care pharmacy team assessed and authorized (or denied) all SABA refill requests, provided education, and facilitated appropriate follow-up using a telephone service. InterventionsUpon receiving a patient-requested SABA refill, the pharmacist identified the reason for the SABA request, assessed asthma control, and determined adherence to daily controllers or spacer use, if applicable. Education was also provided. Data obtained were used to determine SABA refill approval. EvaluationPrimary reasons for SABA refill request were for (1) current symptom management and (2) no refills remaining in the absence of symptoms. Forty-two (50%) SABA refill requests were eligible for refill per the clinic algorithm, yet 70% actually received a refill after assessment by the pharmacist. Asthma control was assessed as 26% well controlled, 38% not well controlled, and 36% very poorly controlled. Forty-eight percent of patients prescribed daily controller medications were deemed adherent. Spacers were used in 43 of 76 (56%) patients using metered dose inhalers. Education was provided to 82% of caregivers. Pharmacists facilitated asthma follow-up visits in 41 of 84 (49%) patients contacted, and 61% of those appointments were kept. ConclusionsPharmacist management of a SABA refill telephone service provides an additional means for delivery of asthma education, facilitates follow-up asthma care, helps to identify patients at risk for increased morbidity and mortality due to the overuse of SABAs, and provides another mechanism for medication refills.

169 - Evaluating HPV Vaccination Rates at Johns Hopkins All Children's Hospital General Pediatrics Clinic

Purpose: Human Papilloma Virus (HPV) infection leads to 26,000 new genitourinary and oropharyngeal cancers yearly. Routine recommendation for HPV adolescent immunization was made in 2007 for girls and 2011 for boys. Although this series is efficacious, HPV vaccination rates remain low nationwide, especially when compared to other vaccines of the adolescent platform. Our Pediatric and Adolescent Medicine clinic is evaluating our current HPV vaccination rates with the goal to reach series completion in at least 80% of our adolescents 13–17 years of age by the use of PDSA cycles.

Investigation of the Satisfaction and Affecting Factors of the Parents Attending to the General Pediatrics Outpatient Clinic

Objection: Patients satisfaction with the healthcare services they receive has been one of the important criteria for evaluating the quality of the services provided. In our study, it was aimed to determine the satisfaction level of the parents and the factors affecting the parents’ satisfaction in accordance with the information obtained from the parents of the patients who applied to the General Pediatric Outpatient Clinic. Material and Methods: This prospective and descriptive study was carried out on 500 parents who applied to the General Pediatric Outpatient Clinic, who had no communication and language problems, and approved the informed consent form. The demographic characteristics of the parents, social security coverage, number and reasons of referral, termination status, effects of waiting for doctor examination and total duration of hospital stay on general satisfaction were examined. Results: The study participants were mothers (51%), fathers (30.4%), and other relatives (18.6%) of the patients with a mean age of 34.1±8.9 years. Pediatric patients were less than 1 year (30.2%), 1-5 years (27%), and more than 5 years of age (42.8%). The parents were primary school (43.6%), middle school (36.6%), and high school graduates (15%). Overall satisfaction rate of the parents was as 72.4 percent. The effect of medical personnel behavior, information, cleanliness and comfort on overall satisfaction was statistically significant. Conclusion: With such studies, it can be ensured that hospitals effectively increase service quality and respond to community expectations.&nbsp;

How to treat “Cough” in general pediatric clinic

How to treat “Cough” in general pediatric clinic

Evaluation of Sleep Safety in Infants: Preliminary results of the pilot study

Objective: The aim of the study was to evaluate the safe sleeping habits of the children, knowledge level of parents about safe sleep and related risk factors. Material and Method: The study carried out in Istanbul University Istanbul Medical Faculty Hospital, Well Child Clinic and General Pediatric Clinic, between September and November 2016. The population of the study consisted of the children between 6-59 months of age and their parents, The survey questions about sleeping habits were asked to the parents during a face-to-face interview. The weight and height of parents were measured and body mass indexes were also calculated. Results: The mean age of the children was 30.0±18.1 months. For the first 6 months 67.4% (n=139) of the babies were breastfed for the first 6 months of their lives was (n=139). At the end of the evaluations it was found that 88.3% (n=18) of the parents shared their rooms with their children, and 27.6% (n=57) of the children slept in supine position. More than half of the parents (60.7%) who shared their beds with their children smoked. Conclusion: Our study revealed the need to provide detailed information about safe sleep habits when providing breastfeeding counseling after birth.

Overweight in children and its perception by parents: cross-sectional observation in a general pediatric outpatient clinic

BackgroundChildhood overweight is a growing problem in industrialized countries. Parents play a major role in the development and the treatment of overweight in their children. A key factor here is the perception of their child’s weight status. As we know of other studies, parental perception of children’s weight status is very poor. This study aimed to determine factors associated with childhood overweight and parental misperception of weight status. The height and weight of children, as reported by parents were compared with measured data.MethodsThe study was conducted at a general pediatric outpatient clinic in Vienna, Austria. A total of 600 children (aged 0–14 years) participated in the study. Collection of data was performed by means of a questionnaire comprising items relating to parental weight and social demographics. The parents were also asked to indicate their children’s weight and height, as well as the estimated weight status. Children were weighed and measured and BMI was calculated, allowing a comparison of estimated values and weight categories with the measured data.ResultsParental BMI, parental weight and a higher birth weight were identified as factors associated with childhood overweight. No association with the parents’ educational status or citizenship could be proven. We compared parents’ estimations of weight and height of their children with measured data. Here we found, that parental estimated values often differ from measured data. Using only parental estimated data to define weight status leads to misclassifications. It could be seen that parents of overweight children tend to underestimate the weight status of their children, compared to parents of children with normal weight.ConclusionsPediatricians should bear in mind that parental assessment often differs from the measured weight of their children. Hence children should be weighed and measured regularly to prevent them from becoming overweight. This is of particular importance in children with higher birth weight and children of overweight parents.Trial registrationStudy was not registered. The study was approved by the Ethic committee of the city of Vienna. (EK 13–146-VK).

Parental Immunisation Needs and Attitudes Survey in paediatric hospital clinics and community maternal and child health centres in Melbourne, Australia.

Despite Australia's high vaccination rates, an estimated 3.3% of children are under-vaccinated due to vaccine refusal and the proportion of parents with concerns is unclear. Amongst Australian parents, we aimed to determine the prevalence of vaccine concerns, resources and health-care providers (HCPs) accessed and satisfaction with these resources in two different settings. We also aimed to identify relationships between the level of vaccine concern, socio-economic status and vaccine uptake. Parents of children under 5 years attending general paediatric clinics in a tertiary paediatric hospital (n = 301/398, 76%) and children under 19 months attending community maternal child health centres (n = 311/391, 81%) completed the survey. Vaccination status was obtained from the Australian Childhood Immunisation Register. Despite high support for vaccination (98%, confidence interval (CI) 97-99), 43% of parents reported vaccine concerns (CI 40-47) including the number of vaccines given in the first 2 years (25%, CI 22 to 29), vaccine ingredients (22%, CI 19-25), allergies (18%, CI 15-21), weakening of the immune system (17%, CI 14-20) and autism (11%, CI 8-13). HCPs were the most commonly accessed and trusted information source. In all, 23% of parents reported insufficient knowledge to make good vaccination decisions (CI 20-26). There was little evidence of an association between parental vaccine acceptance or socio-economic status and vaccination status. Despite high support for vaccines, nearly half of Australian parents have some concerns and a quarter lack vaccine decision-making confidence regarding childhood vaccines. Parents frequently access and report high trust in HCPs, who are best placed to address parental vaccine concerns through provision of clear information, using effective communication strategies. Further research in more highly hesitant populations is required to determine the relationship between the level and nature of vaccination concerns and vaccine uptake.

Improving Human Papilloma Virus Vaccination Rates: Quality Improvement.

Background:Human papilloma virus (HPV) is a sexually transmitted infection with a national prevalence of greater than 70 million. Most infections are among persons 15–24 years of age. The HPV vaccine has nearly 100% efficacy when administered before natural exposure. However, national vaccination rates remain less than 50%. Our objective was to improve the rate of initiation of the HPV vaccination series in a resident teaching practice.Methods:We used the Plan Do Study Act methodology for quality improvement. Eligible patients included children 9 through 13 years of age who presented to a general pediatric clinic. We established baseline data by reviewing HPV immunization rates taken from a convenience sample of ≤20 patients per month over 7 months. A key driver diagram guided interventions including resident communication, nursing staff education, family knowledge, and an electronic medical record prompt beginning at age 9. Using standard run chart rules, we plotted monthly postintervention vaccination rates over 7 months of data collection.Results:Baseline data included 136 patients age 9–13. Run chart monitoring revealed an increase in our HPV vaccination rate from 53% at baseline to 62% by October 2015. Additionally, we observed a statistically significant increase in mean vaccination rates from 50% to 69% (odds ratio 2.071; P = 0.0042). We noted an increase in vaccination rates after resident education initiatives and after implementation of an electronic medical record prompt.Conclusions:Simple and practical interventions involving residents led to a marked increase in HPV vaccination in our patient population.

Video Diversion Improves Success Rate of Fundoscopic Examination in Children: A Prospective Randomized Controlled Trial

BackgroundFundoscopy is an important component of the neurological examination as it can detect pathologies such as high intracranial pressure. However, the examination can be challenging in young children. This study evaluated whether playing a video during eye examination improves the success, duration, and ease of pediatric fundoscopy. Materials and MethodsThis was a prospective, multipractitioner, multiclinic, randomized controlled trial. Patients aged one to four years were recruited in the emergency department, neurology clinic, spinal cord clinic, and general pediatric clinic. Eye examination was randomized to video or non–video-assisted fundoscopy. Successful examinations were defined as visualizing the fundus within 60 seconds. Time to visualize optic disc was recorded and difficulty of examination was assessed using a 10-point Likert scale. ResultsWe recruited 101 subjects with a mean age of 2.8 years. Overall, there was a 20% absolute improvement in the success rate of visualizing the optic disc in the video versus non-video group (P < 0.001, 95%CI: 7.8% to 31%). Time to visualize optic disc was also improved (Δ5.3 seconds, P < 0.01, 95%CI: 1.4 to 9.1 seconds). Practitioners and caregivers noticed a 33% (P < 0.01, 95%CI: 21% to 44%) and 42% (P < 0.01, 95%CI: 30% to 56%) relative improvement in the ease of examination with video, respectively. ConclusionsThe use of videos improved the ease, duration, and, most importantly, the success of fundoscopy in younger children. This simple, inexpensive adjunct has great potential to improve the ease and efficacy of this aspect of the neurological examination and allow fundoscopic examination to be effectively performed earlier in the age-appropriate vision screening protocols.

Hypertension: Under Recorded and Under Recognised in General Paediatric Outpatient Clinics

Hypertension: Under Recorded and Under Recognised in General Paediatric Outpatient Clinics

Pediatric Emergency Department Resource Utilization among Children with Primary Care Clinic Contact in the Preceding 2 Days: A Cross-Sectional Study

To characterize pediatric patient contacts with their primary care clinic in the 2 days preceding a visit to the emergency department (ED) and explore how the type of clinic contact relates to ED resource use. We conducted a retrospective chart review of 368 pediatric ED visits in the first 7 days of each month, from September 2012 to August 2013. Visits were included if the family contacted their child's general pediatric clinic in the study health system in the 2 days preceding the ED visit. Descriptive statistics were calculated. Primary outcomes were ED resource use (tests, treatments) and disposition (admission or discharge). Outcomes by type of clinic contact were compared with χ2 statistics. Of 1116 records with ED visits in the 12 study weeks extracted from the electronic medical record, 368 ED visits met inclusion criteria. Most ED visits followed a single clinic contact (78.8%). Of the 474 clinic contacts, 149 were in-person visits, 216 phone calls when clinic was open, and 109 phone calls when clinic was closed. ED visits that followed an in-person clinic contact with advice to go to the ED had significantly greater rates of testing and admission than those advised to go to the ED after phone contact and those never advised to go to the ED. In-person clinic visits with advice to go to the ED were associated with the greatest ED resource use. Limitations include a study of a single health system without a uniform process for triaging patients to the ED across clinics.

Effect of personal activity trackers on weight loss in families enrolled in a comprehensive behavioral family-lifestyle intervention program in the Federally Qualified Health Center setting: a randomized controlled trial.

BackgroundChildhood obesity continues to be a substantial problem despite major public health efforts, and disproportionately impacts children from low-income families. Digital health tools and consumer technology offer promising opportunities for interventions, but few studies have evaluated how they might be incorporated into existing interventions or used to create new types of interventions. It remains unclear which approaches would be most beneficial for underserved pediatric populations.PurposeTo describe the design and rationale of a single-center randomized, controlled trial evaluating the effects of personal activity tracker (PAT) use by parents on weight-status improvement in both parents and overweight children enrolled in BodyWorks (BW), a comprehensive behavioral family-lifestyle intervention program (CBFLI), in a primary-care clinic serving a predominantly low-income Latino population.MethodsThis study is being conducted in the AltaMed general pediatrics clinic at Children's Hospital Los Angeles. Eligible participants are families (child and adult caregiver) in which the child is between 7 and 18 years of age, has a BMI ≥85th percentile for age and sex, and has been referred to BW by their AltaMed pediatrician. BW consists of one weekly, two-hour session for 7 weeks. In a given cycle, the program is offered on two separate nights: Monday (Spanish) and Wednesday (English). Families self sort into one of two groups based on language preference. To ensure balanced allocation of language preference groups and prevent in-group cross contamination, block randomization is used to assign whole groups to either the intervention or control arms of the study. The control arm consists of usual care, while the intervention arm adds assigning a Fitbit PAT to the parents and training them in its proper use. Study personnel are blinded to group assignment during the analysis phase. Study outcomes include attendance rate, program completion rate, and changes in weight-status improvement, defined as change in weight and BMI for adults and change in BMI z-score for children. We hypothesize that the intervention arm will have better weight-related outcomes than the control arm. Study completion is anticipated in 2017, after the enrollment of approximately 150 families.ConclusionsThe study aim is to evaluate the effects of PATs on weight-related outcomes in overweight children and parents participating in a CBFLI. The results will be important for determining whether wearable devices are an effective addition to weight loss interventions for overweight and obese children.

Managing the pediatric patient with refractory asthma: a multidisciplinary approach.

Children with asthma that is refractory to high levels of prescribed treatment are described as having problematic severe asthma. Those in whom persistent symptoms result from a failure of basic asthma management are described as having “difficult asthma”, while those who remain symptomatic despite these factors having been addressed are described as having “severe therapy-resistant asthma” (STRA). The majority of children have difficult asthma; asthma that is poorly controlled because of a failure to get the basics of asthma management right. Modifiable factors including nonadherence to medication, persistent adverse environmental exposures, and psychosocial factors often contribute to poor control in these patients. As our skill in identifying and addressing modifiable factors has improved, we have found that a progressively smaller proportion of our clinic patients is categorized as having true STRA, resulting in an infrequent resort to escalation of treatment. Many of the modifiable factors associated with the diagnosis of difficult asthma can be identified in a general pediatric clinic. Characterization of more complex factors, however, requires the time, skill, and expertise of multiple health care professionals within the asthma multidisciplinary team. In this review, we will describe the structured approach adopted by The Royal Brompton Hospital in the management of the child with problematic severe asthma. We highlight the roles of members of the multidisciplinary team at various stages of assessment and focus on prominent themes in the identification and treatment of modifiable factors.

Assessment of Parental Knowledge and Understanding of Eating Disorders.

Recommended treatment of adolescent eating disorders includes active parental involvement. The purpose of this study was to assess baseline parental knowledge and understanding of eating disorders and how it is affected by participation in treatment. A cross-sectional and prospective cohort study comparing the parents of children ages 8 to 18 years seeking initial evaluation for an eating disorder at an adolescent medicine clinic (ED) to those attending appointments at a general pediatrics clinic (GP) was performed utilizing a 20-item questionnaire. There was no difference in mean scores at baseline, however after 2 months, the mean score of the ED group was significantly higher, while that of the GP group was not. The change in mean score from the first to second survey was significantly greater for the ED group than the GP group. Increased knowledge may improve self-efficacy, which plays a critical role in parents' ability to adopt eating disorder treatments.

A quality improvement project to reduce waiting time for pediatric outpatient referral clinics in Singapore

Background: The long waiting time in our General Pediatric Clinic results in the delay in diagnosis and treatment leading to increase in morbidity and dissatisfaction rate among sick children who seek treatment at KK Women’s and Children’s Hospital, Singapore. The mean ± SD waiting time in our General Pediatric Clinic increased from 40 ± 4 days in 2008 and 45 ± 7 days in 2009 to 50 ± 5 days in 2010. Objectives: To reduce long waiting times in our General Pediatric Clinic by 20%. Methods: The Reducing Waiting Time Working Group was formed to tackle the waiting time problem in the General Pediatric Clinic. Extensive literature was searched and reviewed, brainstorming and discussions were carried out and strategies were developed. A series of implementations were carried out sequentially including clearing of the backlog of cases, development of general and fast track referral guidelines, triaging system and ‘5 Days SMS and 48 Hours Call’ system. Results: By clearing the backlog cases, waiting time was reduced from 57 days to 44 days. Through effective triaging system and ‘5 Days SMS and 48 Hours Call’ system, the mean ± SD waiting time was further reduced by 30% from 50 ± 5 days to 35 ± 7 days. By June 2012, the mean waiting time was 27 days. Conclusions: Waiting time is one of the important indicators of healthcare quality provided by any healthcare institution. Through these implementations, waiting time was successfully reduced by 30%. These methods may serve as viable options to improve waiting time in other healthcare settings.