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Abstract
Background Interventions to improve care team situation awareness (SA) are associated with reduced rates of unrecognized clinical deterioration in hospitalized children. Recent safety events at our institution revealed common etiologic themes, including 1) inadequate SA for patients demonstrating signs of deterioration, and 2) lack of a shared mental model due to inadequate psychological safety and communication.
Objectives We aimed to decrease emergency transfers (ETs) to the intensive care unit (ICU) by 50% over 10 months.
Methods An interprofessional team of physicians, nurses, respiratory therapists, and families convened to apply innovation to the original SA model for clinical deterioration by addressing emerging corruptors to SA, communication inadequacies, and evolving technology in our inpatient system. Key drivers included establishing a shared mental model, psychologically safe escalation, and efficient and effective SA tools (figure 1). Novel interventions including the intentional inclusion of families and diverse care team roles in huddles, a mental model checklist, door signage, and an electronic health record SA navigator were evaluated via a time series analysis. Sequential inpatient-wide testing of the SA model allowed for iteration and consensus building across care teams and families via qualitative data collection and review. The primary outcome measure was ETs, defined as any ICU transfer where the patient received intubation, inotropes, or ≥3 fluid boluses within one hour of transfer.
Key driver diagram for the SA Model for clinical deterioration
Results The average rate of ETs per 10,000 patient days decreased from 1.57 to 0.49 during the study period (figure 2). This coincided with special cause improvement in all process measures, including earlier recognition of potentially deteriorating patients and increased exemplary utilization of SA tools (figure 3).
Outcome measure: emergency transfers. Statistical process control U-chart of the rate of emergenc transfers per 10,000 patient days. Established rules for shewhart control were utilized to determine if observed changes were due to special causes variation
Process measures. Statistical process control P-charts: A) Percent of patients designated as watchers at least one hour prior to medical response team or code activation. B) Percent of watcher patients who have an SA note filed within two hours of watcher status initiation. C) Percent of watcher patients who have objective medical response team activation criteria. Established rules for Shewhart control charts were utilized to determine If observed changes were due to special cause variation
Conclusions An innovative, proactive, and reliable process to predict, prevent, and respond to clinical deterioration was associated with a nearly 70% reduction in ETs. Importantly, ETs are associated with increased hospital length of stay and mortality.