Watcher Initiative Associated With Decrease in Failure to Rescue Events in Pediatric Population

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Critical Care Medicine

Background:

• Unplanned intensive care unit (ICU) transfers can be associated with serious safety issues, termed unrecognized situation awareness failure events (UNSAFE).
• These UNSAFE transfers are linked to critical interventions like intubation or vasopressor use.
• Improving situation awareness is key to preventing these adverse events.

Purpose of the Study:

• To decrease the proportion of unplanned ICU transfers meeting UNSAFE criteria by 50% within one year.
• To evaluate the effectiveness of a huddle-based intervention in reducing patient safety events during ICU transfers.

Main Methods:

• Adapted a huddle-based intervention involving daily safety briefs and identification of 'watcher patients' at risk for UNSAFE transfers.
• Implemented twice-daily watcher huddles where nurses and residents jointly identified at-risk patients and mitigation plans.
• Rolled out the huddle intervention hospital-wide and retrospectively reviewed electronic medical records to categorize transfers as safe or UNSAFE.

Main Results:

• During the pre-intervention period, 15.5% of unplanned ICU transfers were UNSAFE.
• Post-intervention, the proportion of UNSAFE transfers decreased to 3%, representing an 81% reduction.
• The study successfully exceeded its aim of a 50% reduction in UNSAFE transfers.

Conclusions:

• Daily watcher huddles, integrated into routine inpatient care, are effective in significantly reducing UNSAFE transfers.
• This intervention demonstrates a successful strategy for enhancing patient safety and improving care transitions to the ICU.
• Huddle-based communication fosters collaborative risk identification and mitigation, leading to better patient outcomes.