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Wessman Brian; Sona, Carrie; Schallom, Marilyn; Aycock, Jennifer; Drewry, Anne; Mazuski, John; Boyle, Walter
Critical Care Medicine: December 2013
doi: 10.1097/01.ccm.0000439193.52554.8b
Oral Abstract Session: Administration & Education: PDF Only

Introduction: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Patient care in the critical care setting is incredibly complex and is improved by a multidisciplinary group of providers. A consistent daily care plan is necessary between day/night shift teams and among bedside ICU nurses, consultants, and physicians. With the evolution of ACGME work-hour rules, the number of daily “patient hand-offs” has steadily increased. Our goal was to create a novel, easily accessible communication device to improve ICU patient care. Methods: This communication improvement project was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 214 admissions per month. We created a glass door template embossed on the glass that included three columns for daily goals to be written: “day team”, “night team”, “surgery/consultant team”. Assigned areas for tracking “lines”, “antibiotics”, “ventilator weaning”, and “DVT screening” were also included. These doors are filled out/updated throughout the day by all of the ICU providers. Check boxes are made next to each goal with a subsequent mark added by the bedside nurse when the task is completed. All services can review current plans/active issues while evaluating the patient at the bedside. Patient identifying data is not included. We retrospectively reviewed all ICU safety reported events over a 4-year period (2 years prior and 2 years post glass door implementation) for specific hand-off communication related errors and then compared the two cohorts. Results: Our glass doors are filled out daily on rounds by all services. Prior to implementation, 7.96% of reported errors were related to patient hand-off communication errors. The post glass-door era had 4.26% of reported errors related to patient hand-off communication errors with a relative risk reduction of 46.5%. Due to its usefulness, this method of communication was quickly adopted by the other critical care services (cardiothoracic, medical, neurology/neurosurgery, cardiology) at our institution and is now employed for over 100 ICU beds. A Joint Commission Surveyor stated that this communication tool deserved recognition as a best practice model. Conclusions: Our glass door patient hand-off tool is an easily adaptable intervention that has improved communication between bedside nurses and physicians, our day/night ICU teams, ICU staff members, as well as with our surgery and consultant teams leading to an overall decrease in the number of hand-off communication errors.

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins