Development and implementation of a risk identification tool to facilitate critical care transitions for high-risk surgical patients.

QUALITY PROBLEM: Patients recently discharged from the intensive care unit (ICU) are at high risk for clinical deterioration. INITIAL ASSESSMENT: Unreliable and incomplete handoffs of complex patients contributed to preventable ICU readmissions. Respiratory decompensation was responsible for four times as many readmissions as other causes. CHOICE OF SOLUTION: Form a multidisciplinary team to address care coordination surrounding the transfer of patients from the ICU to the surgical ward. IMPLEMENTATION: A quality improvement intervention incorporating verbal handoffs, time-sensitive patient evaluations and visual cues was piloted over a 1-year period in consecutive high-risk surgical patients discharged from the ICU. Process metrics and clinical outcomes were compared to historical controls. EVALUATION: The intervention brought the primary team and respiratory therapists to the bedside for a baseline examination within 60 min of ward arrival. Stakeholders viewed the intervention as such a valuable adjunct to patient care that the intervention has become a standard of care. While not significant, in a comparatively older and sicker intervention population, the rate of readmissions due to respiratory decompensation was 12.5%, while 35.0% in the control group (P = 0.28). LESSONS LEARNED: The implementation of this ICU transition protocol is feasible and internationally applicable, and results in improved care coordination and communication for a high-risk group of patients.

Improving Providers' Role Definitions to Decrease Overcrowding and Improve In-Hospital Cardiac Arrest Response.

BACKGROUND: How nontechnical factors such as inadequate role definition and overcrowding affect outcomes of in-hospital cardiac arrest (IHCA) is unknown. Using a bundled intervention, we sought to improve providers' role definitions and decrease overcrowding during IHCA events. OBJECTIVES: To determine if a bundled intervention consisting of a nurse/physician leadership dyad, visual cues for provider roles, and a "role check" would lead to reductions in crowding and improve perceptions of communication and team leadership. METHODS: Baseline data on the number and type of IHCA providers were collected. Providers were asked to complete a postevent survey rating communication and leadership. A bundled intervention was then introduced. Data were then obtained for the subsequent IHCA events. RESULTS: Twenty ICHA events were captured before and 34 after the intervention. The number of physicians present at pulse checks 2 (median [interquartile range]: 6 [5-8] before vs 5 [3-6] after, P = .02) and 3 (7 [5-9] vs 4 [4-5], P = .004) decreased significantly after the intervention. The overall number of providers at the third pulse check (18 [14-22] before vs 14 [12-16] after, P = .04) also decreased after the intervention. On a 10-point Likert scale, ratings of communication (8 [7-8]) and physician leadership (8 [7-9]) did not differ significantly from before to after the intervention. Both the physician leads (90%) and patients' primary nurses (97%) were able to identify clear nurse leaders. CONCLUSION: A bundled intervention targeted at improving IHCA response led to a decrease in overcrowding at ICHA events without substantial changes in the perceptions of communication or physician leadership.