PICU Transfers

1. PICU Transfers Tyler W. Buckner, MD April 24, 2009

2. Case #1: PICU Transfer 5/2 0800: 6 yo female with PMH of mild intermittent asthma presented to ED in status asthmaticus 5/2 1700: Transferred to PICU for continuous albuterol nebs

3. Case #1: PICU Transfer 5/2 Overnight: Received contiuous albuterol nebs then transitioned to Q4/Q2 nebs (12 hours of CAT) 5/3 1100: Patient medically ready for transfer to floor (no beds) 5/3 2000: Patient transferred to floor on Q4/Q2 albuterol nebs, steroids, well appearing

4. Case #1: PICU Transfer 5/4 AM: Ward senior called by asthma educator asking for the resident to sign the asthma action plan/paperwork for the patient because she is ready for D/C No ward residents knew this patient. Residents not aware that the patient had been on the floor for 12 hours

5. Case #2: NICU Transfer 21 day old infant, born at 32 wks gestation History of: Respiratory Distress Syndrome (intubated 3 days), R/O Sepsis at birth Active Issues: Nutritional support (PO/NG), Respiratory Insufficiency (on oxygen), and Presumed sepsis (Oxacillin and Gentamicin Day 5/7)

6. Case #2: NICU Transfer 5/31 AM Rounds: Patient medically ready for transfer to the floor. No beds available. 5/31 2000: Bed opens, Patient transferred to the floor. No order written in the chart for patient to be transferred

7. Case #2: NICU Transfer 5/31 2000: Patient Transferred to the floor 6/3 AM: During green team walk rounds the attending noticed a patient that “looked like she should be on the green team” Residents had never seen or heard about this patient HUC: noted that patient’s name on surgery team census in WebCIS

8. Case #2: NICU Transfer Surgery team did not know patient Green team saw and evaluated patient and placed patient on their team Patient had not been seen by an MD from transfer on 5/31 PM until 6/3 AM

9. Overview Project inception and design Review of relevant literature PDSA cycle Results Problems and proposed solutions Quality improvement training during residency

10. Thought process NICU case MICU transfer process Initial thoughts on how to make a change Presentation on QI in NICU Discussion with fellow and attending Thoughts on NICU case; knowing MICU transfer process, wondering whether it would translate to Peds; brainstorming how to make change, who would need to be involved, etcThoughts on NICU case; knowing MICU transfer process, wondering whether it would translate to Peds; brainstorming how to make change, who would need to be involved, etc

11. Where do I start? Mentor identification Familiar with the clinical area affected by the problem Interested in quality improvement research Learn QI basics PDSA cycles Flow charts Review relevant literature

12. ICU Transfers: What does the literature show? Nighttime ICU transfers Increase in number of nighttime discharges from ICU Increase in mortality for discharges to ward at night versus during the day Greater number of “premature” discharges from ICU to wards occur at night

13. ICU Transfers: What does the literature show? Nighttime transfers and morbidity/mortality Night discharges from the ICU associated with increased mortality* Night discharges have increased mortality and increased risk of re-admission to the ICU**

14. ICU Transfers: What does the literature show? Patient Handoffs Residents identified “problems with handoffs” as contributing to 15% of mistakes made that lead to adverse events* Poor handoff communication threatens patient safety for boarders in ED** RR is a result of JCAHO stress on handoffs’ importanceRR is a result of JCAHO stress on handoffs’ importance

15. ICU Transfers: What does the literature show? Barriers to safe patient transfers Survey of ED and Internal Medicine physicians and PA’s 29% reported having had a patient with an adverse event/near miss after ED to inpatient transfer Multiple contributors to errors identified, including difficulty identifying responsible physicians and ambiguous responsibility for sign-out or follow-up Overall literature does not address our specific concern and is too broadOverall literature does not address our specific concern and is too broad

16. Identify scope of problemIdentify scope of problem

17. Indentifying the cause

19. Identify a possible solution Based on MICU transfer process Intended purpose of CPOE transfer order set

21. Identify the interested/affected parties Floor resident PAO, team resident during the day, on-call resident overnight PICU resident Patient’s primary resident, covering resident (Peds and off-service) Floor nurse By floor/unit, starting with nurse managers PICU nurse Nursing manager/supervisor, charge nurses, primary nurses Surgery resident Various services (each with their own policy regarding writing orders)

22. PDSA: Plan Design flow chart Describe each interested party’s role in the process Disseminate this information Plan for continual training/retraining

24. KEY STEPS “OR&R” order put into CPOE by accepting physician ONLY Patient does NOT leave the PICU until an OR&R order has been written by a floor (non-PICU) resident Floor nurse contacts resident who entered OR&R order when patient arrives to floor

25. PICU resident: When patient is deemed suitable for transfer to the floor: enter Transfer order in CPOE do NOT enter “Orders reviewed and revised” order clean up PICU-specific orders call House Supervisor 3-4220 call PAO 216-8160 when a bed is available for the patient: page the PAO and give them a short summary of the patient’s active issues; the PAO will do the transfer or assign the work to the appropriate person

26. Accepting resident: When a patient who is ready for transfer from the PICU has a floor bed available: see the patient, review their orders, write an accept note enter the “Orders reviewed and revised” order in CPOE the floor nurse will page you when the patient gets to the floor. Answer any questions and give the nurse the names of the patient’s primary team’s resident and intern you MUST contact the patient’s primary team’s resident to hand the patient off to them (either sometime during the day or the next morning when you sign out to them) Add the patient to the appropriate group list in WebCIS (new)

27. PICU nurse: When a bed becomes available for a PICU patient to be transferred to the floor: contact the PICU resident, who will contact the accepting resident on the floor; OR page the Pediatric Admitting Pager 216-8160 do not physically transfer the patient to the floor until the accepting floor resident has entered the “Orders reviewed and revised” order in CPOE – this order must be entered by the floor resident, NOT the PICU resident continue to communicate with the PICU resident and the floor resident until the process is complete

28. Floor nurse: When a patient arrives to the floor from the PICU: look for the “Orders reviewed and revised” order in CPOE contact the physician who entered this order (this should be the PAO or the accepting resident/intern) to inform them that the patient is on the floor and to ask any questions you may have concerning the patient if you are unable to reach the accepting resident, contact the PAO or resident on call (216-8160) and inform them that you need to find the patient’s physician

29. PDSA: Do Meet with involved parties to implement new transfer process Limit implementation to transfers from PICU to Peds teams: General, Nephrology, Endocrine, GI, Pulmonary, Cardiology, Heme/Onc, Neurology, Hospitalist, Metabolic Floor nursing roles: implement in CICC only

30. PDSA: Study Data collection method Results Average 2.6 transfers per day from PICU Average time elapsed between OR&R entry and arrival to floor 3 hours, 18 minutes

32. PDSA: Study Data collection method Results Difficult to do individual root-cause analyses for each event in real-time Events continue to occur (anecdotally), but at a perceived decreased rate

33. PDSA: Act Plan for changes to incorporate into next PDSA cycle based on current problems with system Continue to measure effectiveness

35. Problem ? Solution PICU Resident No training in OR&R procedure (especially off-service)

37. Problem ? Solution PICU Resident No training in OR&R procedure (especially off-service) ? Post laminated card with PICU resident instrucitons on all PICU computers and CoW’s

38. Problem ? Solution Floor Resident Not acknowledging/expecting calls from floor staff when transferred patients arrive to floor

40. Problem ? Solution Floor Resident Not acknowledging/expecting calls from floor staff when transferred patients arrive to floor ? Set the expectation that floor residents will make communication with floor nurses for transferred patients a priority (add statement to chief residents’ training module)

41. Problem ? Solution PICU Nurse 1. Does process apply to surgical patients?

43. Problem ? Solution PICU Nurse 1. Does process apply to surgical patients? ? Make OR&R process apply to EVERY patient leaving the PICU (including surgical patients)

44. Problem ? Solution PICU Nurse 2. Floor residents not consistently being called when bed is available

46. Problem ? Solution PICU Nurse 2. Floor residents not consistently being called when bed is available ? Modify PICU Nurse education to encourage RN to call floor resident (via admitting pager) when bed is available

47. Problem ? Solution Floor Nurse 1. Only CICC looks for OR&R

49. Problem ? Solution Floor Nurse 1. Only CICC looks for OR&R ? Expand floor RN instructions to include all Children’s Hospital floors/wards

50. Problem ? Solution Floor Nurse 2. Not yet policy to call MD when pt arrives to floor

52. Problem ? Solution Floor Nurse 2. Not yet policy to call MD when pt arrives to floor ? Institute policy of floor nurse contacting resident who enters OR&R when patient arrives on floor

53. Problem ? Solution Surgery Resident No training in OR&R procedure

55. Problem ? Solution Surgery Resident No training in OR&R procedure ? Communicate with surgical residents via email to explain transfer process

56. Changing the culture We should not be willing to accept ANY missed patients Redefine attitudes toward transfers from the PICU: Floor nurses: responsible for knowing who is caring for a patient and should feel empowered to ask Floor residents: take ownership of all patients on the floor PICU nurses: enforce the rules of the process

57. Why the focus on Quality? Ultimate goal is to improve patient outcomes by enhancing/optimizing provision of medical services Core competencies: systems-based practice RRC requirement Hospital/clinic bottom line: Pay-for-Performance

59. QI opportunities Hospital-wide STEMI team - meets monthly Critical Care Clinical Process Improvement Team - primarily addressing infection reduction at this time - meets alternate months Quality for Women's and Infants PI Committee (QWIPIC) - meets monthly Patient Safety Rounds - taking place in Ped's, Women's and Labs Teams that will be starting soon:  Needlestick reduction Groups addressing reducing iatragenic pneumothorax & accidental lacerations and punctures Emergency Department, Code Committee (with Dr. Larry Katz): optimizing resuscitation efforts at UNC (2 active projects)

60. Acknowledgements Thanks to everyone involved: nurses, residents, faculty, staff Tina Willis, Jordan Erickson, Anna Freeman Carolyn Viall, Roger Saunders, PICU and CICC nursing staff Larry Mandelkehr, Larry Katz Many others

61. References Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care. Ann Emerg Med. 2008 Jun 13. Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005 Dec 12-26;165(22):2607-13. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006 Apr 3;184(7):334-7. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet. 2000 Apr 1;355(9210):1138-42. Pilcher DV, Duke GJ, George C, Bailey MJ, Hart G. After-hours discharge from intensive care increases the risk of readmission and death. Anaesth Intensive Care. 2007 Aug;35(4):477-85.