Improving Communication and Response to Clinical Deterioration to Increase Patient Safety in the Intensive Care Unit.

BACKGROUND: In the critical care setting, early recognition of clinical decompensation is imperative to trigger prompt intervention and optimize patient outcomes. LOCAL PROBLEM: In a 20-bed surgical intensive care unit of an urban academic medical center, cases of clinical deterioration that highlighted opportunities to improve the communication process prompted a reassessment of health care provider roles and responsibilities. METHODS: A quality improvement initiative was implemented to enhance communication among intensive care unit clinical staff members, improve the timeliness of reporting clinical deterioration, and ensure implementation of timely, appropriate interventions to eliminate adverse outcomes. INTERVENTIONS: Nurses were surveyed to determine their perceptions of communication and collaboration among providers. Education was provided that focused on familiarizing nurses with clinical conditions necessitating direct notification of the attending surgical intensivist and included review of a case in which escalation of care did not occur. Multidisciplinary rounds were expanded to engage night-shift nurses in clinical discussions and decision-making. A template was created to document episodes of escalation in the electronic health record. RESULTS: Since implementation of the quality improvement interventions, no incidents of patient harm or death related to failure to escalate have occurred to date. A total of 16 episodes of escalation for clinical deterioration were documented in the electronic health record. Most nurses reported an increased level of confidence in understanding when to escalate concerns about clinical deterioration. CONCLUSION: Implementing a multimodal program to empower nurses to escalate clinical concerns directly to the attending physician eliminated adverse events related to failure to escalate.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19).

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."

Trauma Response Nurse: Bringing Critical Care Experience and Continuity to Early Trauma Care.

Multitrauma patients can benefit significantly from specialized care. Prior to mid-2016, this hospital's trauma team did not include a surgical intensive care unit (SICU) nurse. As the value of bringing this expertise to the patient upon arrival was realized, the role of the trauma response nurse (TRN) was developed. The TRN role was designed to provide a dedicated SICU nurse to care for trauma patients from emergency department (ED) arrival through disposition. The integration of the TRN role into the trauma team sought to improve quality and safety, as well as communication and collaboration, and enhance continuity of care. The primary responsibilities of the TRN were to assist with clinical interventions, transport patients fromthe ED to tests and procedures, and assume care through disposition. Additional TRN duties included education, community outreach, and performance improvement. TRNs now respond to all trauma activations that occur on weekday day shift. This role has improved collaboration between nursing disciplines, improved the overall function of the trauma team, and enhanced the safety of trauma patients during transport. TRNs make valuable contributions to the education and outreach missions of the trauma program and ensure that patients are receiving the highest level of trauma care.