Intervention Improves Staff’s Situational Awareness, Reduces Avoidable ICU Transfers
January 23, 2013 | Risk Management News
Implementation of a system to identify, mitigate, and escalate risk was associated with a near 50% reduction in serious safety events and transfers to intensive care units (ICUs) resulting from unrecognized clinical deterioration, according to the results of a study published online December 10, 2012, in Pediatrics. The study, which was conducted at a 523-bed academic children’s hospital, found that the rate of transfers determined to be “unrecognized situation awareness failures events” per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The researchers identified five risk factors that were determined to be potential predictors of deterioration: (1) family concern about patient safety; (2) high-risk therapies, including unfamiliar therapies on the unit (e.g., insulin use outside of the diabetes unit); (3) elevated early warning scores; (4) “gut feelings” that the patient was at risk for deterioration or “close to the edge”; and (5) communication concerns.