Reducing Unplanned Adverse Events on a Trauma Unit by Improving Critical Thinking

Purpose: Unplanned Adverse Events (UAE) add to the length of time a patient stays in the hospital. UAE’s include unplanned, emergent trips to the OR, ICU, or cardiac or respiratory arrests. Research generally demonstrates that most UAEs can be prevented by thorough nursing assessment of early, subtle changes in patients’ status, and improved critical thinking and clinical decision making about findings that warrant intervention and those that can be observed for further changes.

Objectives:

1. Reduce Unplanned Adverse Events (UAE) by identifying potential patient deterioration early
2. Improve bedside nursing assessment skills, critical thinking, and timely clinical decision making

Methods: A quality improvement project was initiated on the Trauma floor. Clinical Nurse Leaders presented case studies at unit staff meetings and facilitated group discussions. Clinical nurses completed multi-system assessment review programs. Nursing skills and assessment were verified through “check-offs” with unit nursing supervisors. Daily spot-review of charts were performed to assure patient is receiving the highest care and that ordered assessments and interventions are not only completed but documented in a timely manner. Documentation of provider communication and orders received was reviewed. Bedside nursing assessment documentation was strongly encouraged.

Results: The program was successful in achieving its limited goals. UAE’s were reduced by 55% (from 3.35/1000 patient days to 1.5/1000 patient days). Calls for the Rapid Response Team (RRT) were increased by 35% (2.39/1000 to 3.22/1000 patient days). RRTs that were converted to Code Blue (arrests) were reduced by 10% (0.48/1000 patient days to 0.43/1000 patient days).

Conclusions: Immediate education involving case studies of actual patients that had UAEs whom the nursing staff cared for provided both relevancy and the emotional impact necessary for improved and sustained learning.

(Noteworthy fact: Approximately 30-60 ICU days saved with a savings of roughly $230,000 for UAE, total $250,000 - $500,000 cost avoidance.)[1][2]

[1] Rubano, Ja. Unplanned Intensive Care Unit Admission following Trauma. Journal of Critical Care. 2016. Jun 33, 174-9.

[2] Dasta, JF. Daily cost of an Intensive care unit Day. The contribution of Mechanical ventilation. Critical Care Medicine. June, 33 (6), 2005. 1266-71.