scholarly journals Quality Improvement Implementation and Maintenance of a Paediatric Early Warning System

2020 ◽  
Author(s):  
Heather P Duncan ◽  
Amber Oliver ◽  
Karl Emms ◽  
Yvonne Heward ◽  
Adrienne P Hudson
Keyword(s):  
Cardiac Arrest ◽  
Intensive Care ◽  
Quality Improvement ◽  
Action Research ◽  
Hospital Mortality ◽  
Early Warning ◽  
Human Interaction ◽  
Paediatric Intensive Care ◽  
Audit And Feedback ◽  
The Impact

Abstract Background: Paediatric Early Warning (PEW) systems have led to earlier identification and escalation of treatment with subsequent admission to Paediatric Intensive Care (PIC) in deteriorating children. The impact on reductions in cardiac arrest and mortality vary between the heterogeneous studies, showing both unchanged and reduced cardiac arrest, morbidity and mortality. Identifying and managing critical illness on wards is a complex and dynamic process involving technology, human interaction, cultural context and environment. We introduced a PEW system to reduce potentially avoidable cardiac arrest and death.Methods: We report an Implementation Science Quality Improvement (QI) natural experiment using the Medical Research Councils (MRC) Guidelines for Developing and Evaluating Complex Interventions, Action Research, Action Research Theory and methods. The aim of this program was to identify learning, refinement and improvement opportunities to reduce poor outcomes. The interventions were 1) developing an observation and monitoring policy to standardise practice and provide a template for optimal care, 2) standardized charting with an embedded PEW score, 3) clinical skills training, 4) clinical process audit and feedback and 5) outcome surveillance.The process measures were 1) timeliness and impact for unplanned Paediatric Intensive Care (PIC) admissions, 2) clinical assessment skills and 3) chart completion compliance. The outcome measures included 4) total and predictable cardiac arrests and 5) hospital mortality. Data collection started in 2004, the PEW system was implemented in 2008, and the outcomes were reported through 2018.Results: In our specialist children’s hospital, we completed six improvement cycles over 10 years. 1) Timely PIC admissions improved after implementation (39% to 92%). Patients with unplanned PIC admissions had significantly lower severity of illness and mortality but a longer length of stay. 2) Routine clinical observation accuracy improved (66 to 82%) following multimodal training. 3) Chart completion compliance improved (87 to 99%). In 2018, 2% of observations had missing or inaccurate parameters with a consequent inaccurate total PEW score. 4) The total cardiac arrest rate was significantly reduced (0.36 to 0.16 per 1000 admissions). The small numbers of predictable cardiac arrests showed a decreasing trend. 5) Hospital mortality was significantly reduced (3.46 to 2.24 per 1000 admissions). Outcomes improved approximately 18 months after implementation and have not changed significantly since 2010 despite increasing critical care resources in and out of PIC. The impact of the PEW system on these outcomes is possible but not conclusive.Conclusion: Implementation of the PEW system as a complex intervention using QI methods is associated with improved clinical skill accuracy, chart compliance and detection of deterioration associated with more timely unplanned PIC admissions. These improvements were associated with a significant reduction in cardiac arrest and mortality.

scholarly journals Impact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review

10.2196/13782 ◽  
2020 ◽  
Vol 3 (1) ◽  
pp. e13782
Author(s):  
Heidi Mcneill ◽  
Saif Khairat
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Literature Review ◽  
Hospital Mortality ◽  
Patient Outcomes ◽  
Early Warning ◽  
Early Warning Score ◽  
Risk Stratification Tool ◽  
National Early Warning Score ◽  
The Impact

Background Intensive care unit (ICU) readmissions have been shown to increase a patient’s in-hospital mortality and length of stay (LOS). Despite this, no methods have been set in place to prevent readmissions from occurring. Objective The aim of this literature review was to evaluate the impact of ICU readmission on patient outcomes and to evaluate the effect of using a risk stratification tool, the National Early Warning Score (NEWS), on ICU readmissions. Methods A database search was performed on PubMed, Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and ProQuest. In the initial search, 2028 articles were retrieved; after inclusion and exclusion criteria were applied, 12 articles were ultimately used in this literature review. Results This literature review found that patients readmitted to the ICU have an increased mortality rate and LOS at the hospital. The sample sizes in the reviewed studies ranged from 158 to 745,187 patients. Readmissions were most commonly associated with respiratory issues about 18% to 59% of the time. The NEWS has been shown to detect early clinical deterioration in a patient within 24 hours of transfer, with a 95% CI of 0.89 to 0.94 (P<.001), a sensitivity of 93.6% , and a specificity of 82.2%. Conclusions ICU readmissions are associated with worse patient outcomes, including hospital mortality and increased LOS. Without the use of an objective screening tool, the provider has been solely responsible for the decision of patient transfer. Assessment with the NEWS could be helpful in decreasing the frequency of inappropriate transfers and ultimately ICU readmission.

scholarly journals Impact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review (Preprint)

2019 ◽  
Author(s):  
Heidi Mcneill ◽  
Saif Khairat
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Literature Review ◽  
Hospital Mortality ◽  
Patient Outcomes ◽  
Early Warning ◽  
Early Warning Score ◽  
Risk Stratification Tool ◽  
National Early Warning Score ◽  
The Impact

BACKGROUND Intensive care unit (ICU) readmissions have been shown to increase a patient’s in-hospital mortality and length of stay (LOS). Despite this, no methods have been set in place to prevent readmissions from occurring. OBJECTIVE The aim of this literature review was to evaluate the impact of ICU readmission on patient outcomes and to evaluate the effect of using a risk stratification tool, the National Early Warning Score (NEWS), on ICU readmissions. METHODS A database search was performed on PubMed, Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and ProQuest. In the initial search, 2028 articles were retrieved; after inclusion and exclusion criteria were applied, 12 articles were ultimately used in this literature review. RESULTS This literature review found that patients readmitted to the ICU have an increased mortality rate and LOS at the hospital. The sample sizes in the reviewed studies ranged from 158 to 745,187 patients. Readmissions were most commonly associated with respiratory issues about 18% to 59% of the time. The NEWS has been shown to detect early clinical deterioration in a patient within 24 hours of transfer, with a 95% CI of 0.89 to 0.94 (<i>P</i>&lt;.001), a sensitivity of 93.6% , and a specificity of 82.2%. CONCLUSIONS ICU readmissions are associated with worse patient outcomes, including hospital mortality and increased LOS. Without the use of an objective screening tool, the provider has been solely responsible for the decision of patient transfer. Assessment with the NEWS could be helpful in decreasing the frequency of inappropriate transfers and ultimately ICU readmission.

scholarly journals Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project

2021 ◽  
Vol 10 (4) ◽  
pp. e001305
Author(s):  
Zechen Ma ◽  
Mercedes Camargo Penuela ◽  
Madelyn Law ◽  
Divya Joshi ◽  
Han-Oh Chung ◽  
...  
Keyword(s):  
Intensive Care ◽  
Quality Improvement ◽  
Patient Outcomes ◽  
Community Hospital ◽  
Audit And Feedback ◽  
Post Intervention ◽  
Multidisciplinary Intervention ◽  
Improvement Project ◽  
Educational Modules ◽  
The Impact

BackgroundClinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project.MethodsA ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods.ResultsData on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses.DiscussionThe implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.

The presence of liver cirrhosis is a strong negative predictor of survival for patients admitted to the intensive care unit – Cirrhosis in intensive care patients

2021 ◽  
Author(s):  
Jörg Bojunga ◽  
Mireen Friedrich-Rust ◽  
Alica Kubesch ◽  
Kai Henrik Peiffer ◽  
Hannes Abramowski ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Liver Cirrhosis ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Intensive Care Treatment ◽  
Matched Cohort ◽  
Care Treatment ◽  
Cirrhotic Patients ◽  
The Impact ◽  
Cirrhotic Group

Abstract Background and Aims Liver cirrhosis is a systemic disease that substantially impacts the body’s physiology, especially in advanced stages. Accordingly, the outcome of patients with cirrhosis requiring intensive care treatment is poor. We aimed to analyze the impact of cirrhosis on mortality of intensive care unit (ICU) patients compared to other frequent chronic diseases and conditions. Methods In this retrospective study, patients admitted over three years to the ICU of the Department of Medicine of the University Hospital Frankfurt were included. Patients were matched for age, gender, pre-existing conditions, simplified acute physiology score (SAPS II), and therapeutic intervention scoring system (TISS). Results A total of 567 patients admitted to the ICU were included in the study; 99 (17.5 %) patients had liver cirrhosis. A total of 129 patients were included in the matched cohort for the sensitivity analysis. In-hospital mortality was higher in cirrhotic patients than non-cirrhotic patients (p < 0.0001) in the entire and matched cohort. Liver cirrhosis remained one of the strongest independent predictors of in-hospital mortality (entire cohort p = 0.001; matched cohort p = 0.03) along with dialysis and need for transfusion in the multivariate logistic regression analysis. Furthermore, in the cirrhotic group, the need for kidney replacement therapy (p < 0.001) and blood transfusion (p < 0.001) was significantly higher than in the non-cirrhotic group.  Conclusions In the presented study, liver cirrhosis was one of the strongest predictors of in-hospital mortality in patients needing intensive care treatment along with dialysis and the need for ventilation. Therefore, concerted efforts are needed to improve cirrhotic patients’ outcomes, prevent disease progression, and avoid complications with the need for ICU treatment in the early stages of the disease.

Cardiopulmonary resuscitation: special considerations for infants and children with cardiac disease

2007 ◽  
Vol 17 (S4) ◽  
pp. 116-126 ◽  
Author(s):  
Stacie B. Peddy ◽  
Mary Fran Hazinski ◽  
Peter C. Laussen ◽  
Ravi R. Thiagarajan ◽  
George M. Hoffman ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Arrest ◽  
Intensive Care ◽  
Cardiopulmonary Resuscitation ◽  
Intensive Care Units ◽  
Cardiac Disease ◽  
Paediatric Intensive Care ◽  
Cardiac Intensive Care Unit ◽  
Cardiac Intensive Care ◽  
Paediatric Intensive Care Units

AbstractPulseless cardiac arrest, defined as the cessation of cardiac mechanical activity, determined by unresponsiveness, apneoa, and the absence of a palpable central pulse, accounts for around one-twentieth of admissions to paediatric intensive care units, be they medical or exclusively cardiac. Such cardiac arrest is higher in children admitted to a cardiac as opposed to a paediatric intensive care unit, but the outcome of these patients is better, with just over two-fifths surviving when treated in the cardiac intensive care unit, versus between one-sixth and one-quarter of those admitted to paediatric intensive care units. Children who receive chest compressions for bradycardia with pulses have a significantly higher rate of survival to discharge, at 60%, than do those presenting with pulseless cardiac arrest, with only 27% surviving to discharge. This suggests that early resuscitation before the patient becomes pulseless, along with early recognition and intervention, are likely to improve outcomes. Recently published reports of in-hospital cardiac arrests in children can be derived from the multi-centric National Registry of Cardiopulmonary Resuscitation provided by the American Heart Association. The population is heterogeneous, but most arrests occurred in children with progressive respiratory insufficiency, and/or progressive circulatory shock. During the past 4 years at the Children’s Hospital of Philadelphia, 3.1% of the average 1000 annual admissions to the cardiac intensive care unit have received cardiopulmonary resuscitation. Overall survival of those receiving cardiopulmonary resuscitation was 46%. Survival was better for those receiving cardiopulmonary resuscitation after cardiac surgery, at 53%, compared with survival of 33% for pre-operative or non-surgical patients undergoing resuscitation. Clearly there is room for improvement in outcomes from cardiac resuscitation in children with cardiac disease. In this review, therefore, we summarize the newest developments in paediatric resuscitation, with an expanded focus upon the unique challenges and importance of anticipatory care in infants and children with cardiac disease.

scholarly journals Improvement of APACHE II score system for disease severity based on XGBoost algorithm

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yan Luo ◽  
Zhiyu Wang ◽  
Cong Wang
Keyword(s):  
Intensive Care ◽  
Hospital Mortality ◽  
Patient Outcomes ◽  
External Validation ◽  
Apache Ii ◽  
Validation Dataset ◽  
Apache Ii Score ◽  
Severity Scores ◽  
The Impact ◽  
Improve Patient

Abstract Background Prognostication is an essential tool for risk adjustment and decision making in the intensive care units (ICUs). In order to improve patient outcomes, we have been trying to develop a more effective model than Acute Physiology and Chronic Health Evaluation (APACHE) II to measure the severity of the patients in ICUs. The aim of the present study was to provide a mortality prediction model for ICUs patients, and to assess its performance relative to prediction based on the APACHE II scoring system. Methods We used the Medical Information Mart for Intensive Care version III (MIMIC-III) database to build our model. After comparing the APACHE II with 6 typical machine learning (ML) methods, the best performing model was screened for external validation on anther independent dataset. Performance measures were calculated using cross-validation to avoid making biased assessments. The primary outcome was hospital mortality. Finally, we used TreeSHAP algorithm to explain the variable relationships in the extreme gradient boosting algorithm (XGBoost) model. Results We picked out 14 variables with 24,777 cases to form our basic data set. When the variables were the same as those contained in the APACHE II, the accuracy of XGBoost (accuracy: 0.858) was higher than that of APACHE II (accuracy: 0.742) and other algorithms. In addition, it exhibited better calibration properties than other methods, the result in the area under the ROC curve (AUC: 0.76). we then expand the variable set by adding five new variables to improve the performance of our model. The accuracy, precision, recall, F1, and AUC of the XGBoost model increased, and were still higher than other models (0.866, 0.853, 0.870, 0.845, and 0.81, respectively). On the external validation dataset, the AUC was 0.79 and calibration properties were good. Conclusions As compared to conventional severity scores APACHE II, our XGBoost proposal offers improved performance for predicting hospital mortality in ICUs patients. Furthermore, the TreeSHAP can help to enhance the understanding of our model by providing detailed insights into the impact of different features on the disease risk. In sum, our model could help clinicians determine prognosis and improve patient outcomes.

Implementation of a multimodal patient safety improvement program “SafetyLEAP” in intensive care units

2018 ◽  
Vol 31 (2) ◽  
pp. 140-149 ◽  
Author(s):  
Chantal Backman ◽  
Paul C. Hebert ◽  
Alison Jennings ◽  
David Neilipovitz ◽  
Omar Choudhri ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Quality Improvement ◽  
Intensive Care Units ◽  
Audit And Feedback ◽  
Improvement Program ◽  
Convenience Sample ◽  
Content Type ◽  
Safety Improvement ◽  
Patient Safety Improvement

Purpose Patient safety remains a top priority in healthcare. Many organizations have developed systems to monitor and prevent harm, and have invested in different approaches to quality improvement. Despite these organizational efforts to better detect adverse events, efficient resolution of safety problems remains a significant challenge. The authors developed and implemented a comprehensive multimodal patient safety improvement program called SafetyLEAP. The term “LEAP” is an acronym that highlights the three facets of the program including: a Leadership and Engagement approach; Audit and feedback; and a Planned improvement intervention. The purpose of this paper is to evaluate the implementation of the SafetyLEAP program in the intensive care units (ICUs) of three large hospitals. Design/methodology/approach A comparative case study approach was used to compare and contrast the adherence to each component of the SafetyLEAP program. The study was conducted using a convenience sample of three (n=3) ICUs from two provinces. Two reviewers independently evaluated major adherence metrics of the SafetyLEAP program for their completeness. Analysis was performed for each individual case, and across cases. Findings A total of 257 patients were included in the study. Overall, the proportion of the SafetyLEAP tasks completed was 64.47, 100, and 26.32 percent, respectively. ICU nos 1 and 2 were able to identify opportunities for improvement, follow a quality improvement process and demonstrate positive changes in patient safety. The main factors influencing adherence were the engagement of a local champion, competing priorities, and the identification of appropriate resources. Practical implications The SafetyLEAP program allowed for the identification of processes that could result in patient harm in the ICUs. However, the success in improving patient safety was dependent on the engagement of the care teams. Originality/value The authors developed an evidence-based approach to systematically and prospectively detect, improve, and evaluate actions related to patient safety.

Early Warning Score Communication Bundle: A Pilot Study

2018 ◽  
Vol 27 (3) ◽  
pp. 238-242
Author(s):  
Cheryl Gagne ◽  
Susan Fetzer
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Early Warning ◽  
Rapid Response Team ◽  
Rapid Response ◽  
Early Warning Score ◽  
Early Warning Scores ◽  
Response Team ◽  
Intensive Care Unit Nurses ◽  
The Impact

Background Unplanned admissions of patients to intensive care units from medical-surgical units often result from failure to recognize clinical deterioration. The early warning score is a clinical decision support tool for nurse surveillance but must be communicated to nurses and implemented appropriately. A communication process including collaboration with experienced intensive care unit nurses may reduce unplanned transfers. Objective To determine the impact of an early warning score communication bundle on medical-surgical transfers to the intensive care unit, rapid response team calls, and morbidity of patients upon intensive care unit transfer. Methods After an early warning score was electronically embedded into medical records, a communication bundle including notification of and telephone collaboration between medical-surgical and intensive care unit nurses was implemented. Data were collected 3 months before and 21 months after implementation. Results Rapid response team calls increased nonsignificantly during the study period (from 6.47 to 8.29 per 1000 patient-days). Rapid response team calls for patients with early warning scores greater than 4 declined (from 2.04 to 1.77 per 1000 patient-days). Intensive care unit admissions of patients after rapid response team calls significantly declined (P = .03), as did admissions of patients with early warning scores greater than 4 (P = .01), suggesting that earlier intervention for patient deterioration occurred. Documented reassessment response time declined significantly to 28 minutes (P = .002). Conclusion Electronic surveillance and collaboration with experienced intensive care unit nurses may improve care, control costs, and save lives. Critical care nurses have a role in coaching and guiding less experienced nurses.

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