Hermanson Sarah, Osborn Scott, Gordanier Christin, Coates Evan, Williams Barbara, Blackmore Craig
Center for Health Care Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, USA.
BMJ Open Qual. 2020 Mar;9(1). doi: 10.1136/bmjoq-2019-000862.
Patients admitted to the hospital and requiring a subsequent transfer to a higher level of care have increased morbidity, mortality and length of stay compared with patients who do not require a transfer during their hospital stay. We identified that a high number of patients admitted to our intermediate care (IMC) unit required a rapid response team (RRT) call and an early (<24 hours) transfer to the intensive care unit (ICU). A quality improvement project was initiated with the goal to reduce subsequent early transfers to the ICU and RRT calls. We started by focusing on IMC patients, implementing acuity-based nursing assignments and standardised daily nursing rounds in the IMC aiming to reduce early patient transfers to the ICU. Then, we expanded to all patients admitted to a hospital medical unit from the emergency department (ED), targeting patients with gastrointestinal (GI) bleed and sepsis who were at a higher risk for early transfer to the ICU. We then created an ED intake huddle process that over time was refined to target patients with SIRS criteria with an elevated serum lactic acid level greater than 2.0 mmol/L or a GI bleed with a haematocrit value less than 24%. These interventions resulted in an 10.8 percentage points (31.7% (225/710) to 20.9% (369/1764)) decrease in the early transfers to the ICU for all hospital medicine patients admitted to the hospital from the ED. Mean RRT calls/day decreased by 17%, from 3.0 mean calls/day preintervention to 2.5 mean calls/day postintervention. These quality improvement initiatives have sustained successful outcomes for over 6 years due to integrating enhanced team communication as organisational cultural norm that has become the standard.
与住院期间无需转院的患者相比，入院后需要随后转至更高护理级别的患者发病率、死亡率和住院时间均有所增加。我们发现，大量入住我们中级护理（IMC）病房的患者需要快速反应团队（RRT）呼叫，并需要在早期（<24小时）转至重症监护病房（ICU）。启动了一项质量改进项目，目标是减少随后早期转至ICU的情况以及RRT呼叫。我们首先关注IMC患者，在IMC实施基于 acuity 的护理任务分配和标准化每日护理查房，旨在减少患者早期转至ICU的情况。然后，我们将范围扩大到从急诊科（ED）入院至医院内科病房的所有患者，目标是患有胃肠道（GI）出血和脓毒症且早期转至ICU风险较高的患者。随后，我们创建了一个ED入院碰头流程，随着时间的推移，该流程经过完善，以针对符合全身炎症反应综合征（SIRS）标准且血清乳酸水平升高大于2.0 mmol/L或血细胞比容值小于24%的胃肠道出血患者。这些干预措施使从ED入院的所有医院内科患者早期转至ICU的情况减少了10.8个百分点（从31.7%（225/710）降至20.9%（369/1764））。平均每天的RRT呼叫次数减少了17%，从干预前的平均每天3.0次呼叫降至干预后的平均每天2.5次呼叫。由于将加强团队沟通作为组织文化规范进行整合并已成为标准，这些质量改进举措在6年多的时间里持续取得了成功成果。
