Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events

Abstract

Background and objective: Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥ 3 fluid boluses in first hour after arrival or before transfer.

Methods: The setting for our observational time series study was a quaternary care children's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread.

Results: The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.

Conclusions: A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.

FIGURE 1

Identify, mitigate, and escalate model illustrates which risk factors were systematically identified and how standardized communication about risk occurred throughout the center.

FIGURE 2

Key driver diagram illustrates the drivers (at right) that would lead to aim through improved situation awareness and no unrecognized clinical deterioration.

FIGURE 3

Situation awareness algorithm illustrates the tool used during education and early phases and the specific questions and communication pathways.

FIGURE 4

Situation awareness robust planning tool.

FIGURE 5

Process measure run chart illustrating the number of units by week where ≥90% of weekly nursing shifts fully identified patients at risk (solid line/diamond) and where ≥90% of weekly shifts fully mitigated or escalated that risk (dotted line/circle).

FIGURE 6

UNSAFE transfer rate chart. Rate of UNSAFE transfers per 10,000 non-ICU patient days at base location by month (n = non-ICU inpatient days by month).

FIGURE 7

Rate of MRT activations and transfers to ICU by month.

FIGURE 8

Rate of MRT preventable codes outside of the ICU by month.