Melanie McClain Smith1,2, Maryanne Chumpia3,2, Lindsey Wargo3,2, Julie Nicol3, Mark Bugnitz3,2. 1. Le Bonheur Children's Hospital, Memphis, Tennessee; and melmcc88@gmail.com. 2. Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee. 3. Le Bonheur Children's Hospital, Memphis, Tennessee; and.
Abstract
BACKGROUND AND OBJECTIVES: Improved situation awareness may prevent unplanned ICU transfers. Transfers with serious safety issues may be classified as unrecognized situation awareness failure events (UNSAFE) and are associated with intubation, vasopressors, or >3 fluid boluses within 1 hour before or after ICU arrival. Our aim was to decrease the proportion of unplanned ICU transfers that met UNSAFE criteria by 50% in 1 year. METHODS: We adapted a previously described huddle-based intervention. In May 2015, we started a daily safety brief with hospital-wide representation; concurrently, nurses and residents separately identified watcher patients (ie, patients at risk for UNSAFE transfers) to be reported in the daily safety brief. Watcher patients frequently differed between the groups, so in July 2015, we started twice-daily watcher huddles on a pilot floor. During these huddles, nurses and residents jointly identified watcher patients on the basis of defined criteria and deployed mitigation plans. By March 2016, we implemented these huddles hospital-wide. We reviewed the electronic medical record to categorize all unplanned ICU transfers as safe or UNSAFE. Our outcome was the proportion of unplanned ICU transfers that met UNSAFE criteria. RESULTS: In the 16-month pre-intervention period, 49 of the 322 unplanned ICU transfers were UNSAFE (median 15.5%); in the 12-month post-intervention period, 13 of the 329 unplanned ICU transfers were UNSAFE (median 3%). These findings represent an 81% reduction in the proportion of UNSAFE transfers. CONCLUSIONS: Watcher huddles incorporated into the daily inpatient routine can significantly decrease UNSAFE transfers.
BACKGROUND AND OBJECTIVES: Improved situation awareness may prevent unplanned ICU transfers. Transfers with serious safety issues may be classified as unrecognized situation awareness failure events (UNSAFE) and are associated with intubation, vasopressors, or >3 fluid boluses within 1 hour before or after ICU arrival. Our aim was to decrease the proportion of unplanned ICU transfers that met UNSAFE criteria by 50% in 1 year. METHODS: We adapted a previously described huddle-based intervention. In May 2015, we started a daily safety brief with hospital-wide representation; concurrently, nurses and residents separately identified watcher patients (ie, patients at risk for UNSAFE transfers) to be reported in the daily safety brief. Watcher patients frequently differed between the groups, so in July 2015, we started twice-daily watcher huddles on a pilot floor. During these huddles, nurses and residents jointly identified watcher patients on the basis of defined criteria and deployed mitigation plans. By March 2016, we implemented these huddles hospital-wide. We reviewed the electronic medical record to categorize all unplanned ICU transfers as safe or UNSAFE. Our outcome was the proportion of unplanned ICU transfers that met UNSAFE criteria. RESULTS: In the 16-month pre-intervention period, 49 of the 322 unplanned ICU transfers were UNSAFE (median 15.5%); in the 12-month post-intervention period, 13 of the 329 unplanned ICU transfers were UNSAFE (median 3%). These findings represent an 81% reduction in the proportion of UNSAFE transfers. CONCLUSIONS: Watcher huddles incorporated into the daily inpatient routine can significantly decrease UNSAFE transfers.
Authors: Maya Dewan; Naveen Muthu; Eric Shelov; Christopher P Bonafide; Patrick Brady; Daniela Davis; Eric S Kirkendall; Dana Niles; Robert M Sutton; Danielle Traynor; Ken Tegtmeyer; Vinay Nadkarni; Heather Wolfe Journal: Pediatr Crit Care Med Date: 2020-02 Impact factor: 3.624
Authors: Maya Dewan; Blaise Soberano; Tina Sosa; Matthew Zackoff; Philip Hagedorn; Patrick W Brady; Ranjit S Chima; Erika L Stalets; Lindsey Moore; Maria Britto; Robert M Sutton; Vinay Nadkarni; Ken Tegtmeyer; Heather Wolfe Journal: Pediatr Crit Care Med Date: 2022-01-01 Impact factor: 3.971
Authors: Maya Dewan; Amanda O'Halloran; Monica Kleinman; Ken Tegtmeyer; Regan Gallagher; Vinay Nadkarni; Robert M Sutton; Heather A Wolfe Journal: Pediatr Crit Care Med Date: 2020-11 Impact factor: 3.624