Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma-Based Quality...

Area of Science:

• Pediatric critical care medicine
• Quality improvement science
• Healthcare systems engineering

Background:

• Ineffective patient transfers increase medical errors, posing risks to patient safety.
• Improving patient transfer processes is a key goal for healthcare institutions.
• Current protocols involve postanesthesia care unit (PACU) admission before Pediatric Intensive Care Unit (PICU) transfer for nonintubated pediatric patients.

Purpose of the Study:

• To enhance the patient transfer process from the operating room (OR) to the PICU.
• To implement a structured, direct OR-PICU transfer protocol for orthopedic spinal fusion patients.
• To evaluate the impact of the new process on patient safety and efficiency.

Main Methods:

• Value stream mapping was used to identify inefficiencies in the baseline transfer process.
• A structured, direct OR-PICU transfer process was implemented.
• Primary outcomes included reduction in handoff errors and transfer process time.
• Staff satisfaction was assessed as a secondary outcome measure.

Main Results:

• The handoff communication error rate decreased from 1.9 to 0.3 errors per patient (P = .002).
• Patient wait time and non-value-adding activities were reduced by 58 minutes (from 90 to 32 minutes).
• Information omissions during handoff decreased significantly (P < .001).
• Staff satisfaction notably improved among PICU providers.

Conclusions:

• A quality improvement initiative successfully redesigned the OR-PICU transfer process.
• The new direct transfer protocol with structured handoffs improved patient safety and efficiency.
• Sustained improvements in handoff communication, error reduction, and efficiency were achieved.
• High staff satisfaction indicates successful implementation and acceptance of the new process.