Kupferschmid Megan, Tripathi Sandeep
Pediatric Intensive Care Unit, OSF Healthcare Children's Hospital of Illinois, Peoria, Ill.
Pediatr Qual Saf. 2021 Dec 7;6(6):e536. doi: 10.1097/pq9.0000000000000536. eCollection 2021 Nov-Dec.
Delirium is a preventable cause of ICU morbidity and mortality. Prior unstructured efforts to implement delirium screening in our hospital were unsuccessful. This project aimed to improve the delirium screening compliance from baseline 0% to more than 80% within 12 months (07/2019-06/2020).
We utilized Kotter's stages of transformation as guiding blocks for implementing change and undertook simultaneous efforts to decrease delirium rates. In addition, we used statistical process control to monitor screening compliance and delirium rates.
Education on delirium assessment and prevention created a sense of urgency among nursing and medical staff (Stage #1). Stakeholder analysis and a key driver diagram were presented to leadership to create a guiding coalition (Stage #2). Process mapping and failure mode and effect analysis created a vision and strategy for the project (Stage #3). Multiple methods were utilized to communicate the change vision (Stage #4) and empower broad-based action (Stage #5). We celebrated small incremental achievements or short-term wins (Stage #6) by reporting delirium compliance and rate on a control chart. We completed 5837 delirium screens on 763 patients (6689 opportunities). The median delirium screening compliance rate was 87.2% (13.4% positive screens). Small achievements produced by the project were communicated to staff, propelling future efforts to recognize and prevent delirium. This momentum was a driver for more change (Stage #7) to ensure a long-term cultural change in the unit (Stage #8).
Kotter's principle of change management, along with an emphasis on data-driven process control, may result in sustained improvement.
谵妄是重症监护病房（ICU）发病和死亡的一个可预防原因。此前在我们医院进行的非结构化谵妄筛查工作未取得成功。本项目旨在在12个月内（2019年7月至2020年6月）将谵妄筛查的依从率从基线的0%提高到80%以上。
我们利用科特变革阶段作为实施变革的指导框架，并同时努力降低谵妄发生率。此外，我们使用统计过程控制来监测筛查依从率和谵妄发生率。
关于谵妄评估和预防的教育在护理和医务人员中营造了紧迫感（第1阶段）。向领导层展示了利益相关者分析和关键驱动因素图，以建立一个指导联盟（第2阶段）。流程映射以及失效模式与效应分析为该项目制定了愿景和战略（第3阶段）。采用多种方法传达变革愿景（第4阶段）并推动广泛参与的行动（第5阶段）。我们通过在控制图上报告谵妄依从率和发生率来庆祝小的渐进式成就或短期胜利（第6阶段）。我们对763名患者（6689次机会）进行了5837次谵妄筛查。谵妄筛查依从率的中位数为87.2%（阳性筛查率为13.4%）。该项目取得的小成就向工作人员进行了传达，推动了未来识别和预防谵妄的工作。这一势头成为更多变革的驱动力（第7阶段），以确保该科室实现长期的文化变革（第8阶段）。
科特变革管理原则，加上对数据驱动的过程控制的重视，可能会带来持续的改进。
