Reducing cardiac arrests in the acute admissions unit: a quality improvement journey

Abstract

BackgroundIn 2010, the acute admissions unit (AAU) at Stirling Royal Infirmary had the highest number of cardiac arrests of any ward. A quality improvement project was undertaken to reduce this to <1/1000 admissions by December 2011.MethodsIn January 2011, based on initial needs assessment, we selected three initiatives to improve cardiac arrest rate: (1) structured response to deteriorating patients; (2) analysis of adverse events; and (3) improved end-of-life decision-making. We performed a failure modes effects analysis to identify reasons for the failure of early recognition and response. Ward staff conducted weekly safety meetings to engage unit staff and promote a safety culture of continuous improvement. Additionally, in July 2011 the unit adopted a ward-based clinical team structure with twice daily consultant ward rounds. Our primary outcome measure, cardiac arrests per 1000 admissions, was measured from January 2011 to August 2012.ResultsOver 17 months, the number of cardiac arrests per 1000 admissions fell from a baseline of 2.8/1000 admissions to 0.8/1000 admissions (71% reduction), referrals to palliative care increased by 22 to 37/1000 admissions per month (68% increase) and the 30-day mortality of patients admitted to the AAU fell from 6.3% to 4.8% (24% relative reduction).ConclusionsThrough adoption of a shared goal, application of improvement methodology including the model for improvement to test new innovations, and promotion of a safety culture in the AAU, cardiac arrests were successfully reduced to <1/1000 admissions per month with an associated significant fall in mortality. This was achieved with negligible cost.

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre

“…A further factor underlying the potential benefits of SIBR is geographic alignment of patients, given prior studies showing that geographic fragmentation contributes to interprofessional silos and hierarchies, adversely affects team work and clarity in plans and leads to communication gaps 14 15. In contrast, geographic alignment fosters mutual respect, cohesiveness, communication, timeliness and face-to-face problem solving, which may improve hospital outcomes 14 15.…”

“…A further factor underlying the potential benefits of SIBR is geographic alignment of patients, given prior studies showing that geographic fragmentation contributes to interprofessional silos and hierarchies, adversely affects team work and clarity in plans and leads to communication gaps 14 15. In contrast, geographic alignment fosters mutual respect, cohesiveness, communication, timeliness and face-to-face problem solving, which may improve hospital outcomes 14 15. Building on the Stein et al model of an accountable care unit, our SIBR unit encompassed unit-based teams and unit level performance reporting9 and sought to cultivate a positive work environment and a sense of collaborative practice, which in turn may improve communication and shared decision-making 16…”

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

“…This approach is illustrated by Beckett et al in a recent paper about decreasing cardiac arrests in the acute hospital setting,63 “Key to this success has been the development of a structured response to the deteriorating patient. Following the implementation of reliable EWS [early warning systems] across the AAU[Acute Admissions Unit] and ED [Emergency Department], and the recognition and response checklists, plus weekly safety meetings in the AAU at SRI[Stirling Royal Infirmary], there was an immediate fall in the number of cardiac arrests, which was sustained thereafter.”63 This linkage serves to reintroduce the reader to some of the relevant contextual elements which can subsequently be discussed in more detail as appropriate. Importantly, it also serves to frame the interpretive section of the discussion which focuses on comparison of results with findings from other publications, and further evaluating the project's impact.…”

Effects of a computerized feedback intervention on safety performance by junior doctors: results from a randomized mixed method study

“…Further research is needed to clarify how information should be presented, in terms of information provided, place on the screen, format and colour [27,28]. Personalised feedback has also been shown to improve patient safety [29] while the timing, format and the value of the information provided are crucial to eliciting compliance [12,30]. In relation to junior doctors in particular, CDSSs may need to be engineered to take account of their lack of biomedical and experiential knowledge base and their limited expertise in framing clinical situations [31].…”