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Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit

Rehder, Kyle J. MD; Uhl, Tammy L. RN, MSN, CCNS; Meliones, Jon N. MD, MS; Turner, David A. MD; Smith, P. Brian MD, MPH, MHS; Mistry, Kshitij P. MD, MSc

Pediatric Critical Care Medicine: January 2012 - Volume 13 - Issue 1 - p 6–10
doi: 10.1097/PCC.0b013e3182192a6c
Feature Articles

Objective: To improve communication during daily rounds using sequential interventions.

Design: Prospective cohort study.

Setting: Multidisciplinary pediatric intensive care unit in a university hospital.

Subjects: The multidisciplinary rounding team in the pediatric intensive care unit, including attending physicians, physician trainees, and nurses.

Interventions: Daily rounds on 736 patients were observed over a 9-month period. Sequential interventions were timed 8–12 wks apart: 1) implementing a new resident daily progress note format; 2) creating a performance improvement “dashboard”; and 3) documenting patients' daily goals on bedside whiteboards.

Measurements and Main Results: After all interventions, team agreement with the attending physician's stated daily goals increased from 56.9% to 82.7% (p < .0001). Mean agreement increased for each provider category: 65.2% to 88.8% for fellows (p < .0001), 55.0% to 83.8% for residents (p < .0001), and 54.1% to 77.4% for nurses (p < .0001). In addition, significant improvements were noted in provider behaviors after interventions. Barriers to communication (bedside nurse multitasking during rounds, interruptions during patient presentations, and group disassociation) were reduced, and the use of communication facilitators (review of the prior day's goals, inclusion of bedside nurse input, and order read-back) increased. The percentage of providers reporting being “very satisfied” or “satisfied” with rounds increased from 42.6% to 78.3% (p < .0001).

Conclusions: Shared agreement of patients' daily goals among key healthcare providers can be increased through process-oriented interventions. Improved agreement will potentially lead to improved quality of patient care and reduced medical errors.

From the Division of Pediatric Critical Care Medicine (KJR, TLU, JNM, DAT) and the Division of Neonatology (PBS), Duke University Medical Center, Durham, NC; and the Division of Pediatric Cardiovascular Intensive Care, Levine Children's Hospital at Carolinas Medical Center, Charlotte, NC.

Supported by departmental funds; P.B.S. received support from the National Institute of Child Health and Human Development 1K23HD060040-01.

This study was performed at Duke University Medical Center.

The authors have not disclosed any potential conflicts of interest.

No reprints are requested at this time.

For information regarding this article, E-mail: kyle.rehder@duke.edu

©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies