Delayed Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures: A Root Cause Analysis of Unplanned ICU Admissions

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2016 Aug 19

PMID 27537689

Citations 30

Authors

Louise S van Galen

Patricia W Struik

Babiche E J M Driesen

Hanneke Merten

Jeroen Ludikhuize

Johannes I van der Spoel

Mark H H Kramer

Prabath W B Nanayakkara

Affiliations

Soon will be listed here.

Abstract

Background: An unplanned ICU admission of an inpatient is a serious adverse event (SAE). So far, no in depth-study has been performed to systematically analyse the root causes of unplanned ICU-admissions. The primary aim of this study was to identify the healthcare worker-, organisational-, technical,- disease- and patient- related causes that contribute to acute unplanned ICU admissions from general wards using a Root-Cause Analysis Tool called PRISMA-medical. Although a Track and Trigger System (MEWS) was introduced in our hospital a few years ago, it was implemented without a clear protocol. Therefore, the secondary aim was to assess the adherence to a Track and Trigger system to identify deterioration on general hospital wards in patients eventually transferred to the ICU.

Methods: Retrospective observational study in 49 consecutive adult patients acutely admitted to the Intensive Care Unit from a general nursing ward. 1. PRISMA-analysis on root causes of unplanned ICU admissions 2. Assessment of protocol adherence to the early warning score system.

Results: Out of 49 cases, 156 root causes were identified. The most frequent root causes were healthcare worker related (46%), which were mainly failures in monitoring the patient. They were followed by disease-related (45%), patient-related causes (7, 5%), and organisational root causes (3%). In only 40% of the patients vital parameters were monitored as was instructed by the doctor. 477 vital parameter sets were found in the 48 hours before ICU admission, in only 1% a correct MEWS was explicitly documented in the record.

Conclusions: This in-depth analysis demonstrates that almost half of the unplanned ICU admissions from the general ward had healthcare worker related root causes, mostly due to monitoring failures in clinically deteriorating patients. In order to reduce unplanned ICU admissions, improving the monitoring of patients is therefore warranted.

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References

Runciman W, Hibbert P, Thomson R, van der Schaaf T, Sherman H, Lewalle P . Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care. 2009; 21(1):18-26. PMC: 2638755. DOI: 10.1093/intqhc/mzn057. View

Zegers M, de Bruijne M, Wagner C, Hoonhout L, Waaijman R, Smits M . Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009; 18(4):297-302. DOI: 10.1136/qshc.2007.025924. View

Vlayen A, Verelst S, Bekkering G, Schrooten W, Hellings J, Claes N . Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract. 2011; 18(2):485-97. DOI: 10.1111/j.1365-2753.2010.01612.x. View

Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J . The Quality in Australian Health Care Study. Med J Aust. 1995; 163(9):458-71. DOI: 10.5694/j.1326-5377.1995.tb124691.x. View

Moon A, Cosgrove J, Lea D, Fairs A, Cressey D . An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation. 2010; 82(2):150-4. DOI: 10.1016/j.resuscitation.2010.09.480. View

Frost S, Alexandrou E, Bogdanovski T, Salamonson Y, Parr M, Hillman K . Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk. Resuscitation. 2008; 80(2):224-30. DOI: 10.1016/j.resuscitation.2008.10.030. View

van Wagtendonk I, Smits M, Merten H, Heetveld M, Wagner C . Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010; 97(11):1730-40. DOI: 10.1002/bjs.7201. View

Chan P, Khalid A, Longmore L, Berg R, Kosiborod M, Spertus J . Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008; 300(21):2506-13. DOI: 10.1001/jama.2008.715. View

Runciman W, Williamson J, Deakin A, Benveniste K, Bannon K, Hibbert P . An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care. 2006; 15 Suppl 1:i82-90. PMC: 2464872. DOI: 10.1136/qshc.2005.017467. View

10.

Leape L, Brennan T, Laird N, Lawthers A, Localio A, BARNES B . The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324(6):377-84. DOI: 10.1056/NEJM199102073240605. View

11.

Zimmerman J, Kramer A, McNair D, Malila F . Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006; 34(5):1297-310. DOI: 10.1097/01.CCM.0000215112.84523.F0. View

12.

Bapoje S, Gaudiani J, Narayanan V, Albert R . Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med. 2011; 6(2):68-72. DOI: 10.1002/jhm.812. View

13.

Quinn T, Gabriel R, Dutton R, Urman R . Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit. J Intensive Care Med. 2016; 32(7):436-443. DOI: 10.1177/0885066615622124. View

14.

Subbe C, Gao H, Harrison D . Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med. 2007; 33(4):619-24. DOI: 10.1007/s00134-006-0516-8. View

15.

Sherman H, Castro G, Fletcher M, Hatlie M, Hibbert P, Jakob R . Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Health Care. 2009; 21(1):2-8. PMC: 2638753. DOI: 10.1093/intqhc/mzn054. View

16.

van Galen L, Dijkstra C, Ludikhuize J, Kramer M, Nanayakkara P . A Protocolised Once a Day Modified Early Warning Score (MEWS) Measurement Is an Appropriate Screening Tool for Major Adverse Events in a General Hospital Population. PLoS One. 2016; 11(8):e0160811. PMC: 4975404. DOI: 10.1371/journal.pone.0160811. View

17.

Alam N, Vegting I, Houben E, van Berkel B, Vaughan L, Kramer M . Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department. Resuscitation. 2015; 90:111-5. DOI: 10.1016/j.resuscitation.2015.02.011. View

18.

Hillman K, Parr M, Flabouris A, Bishop G, Stewart A . Redefining in-hospital resuscitation: the concept of the medical emergency team. Resuscitation. 2001; 48(2):105-10. DOI: 10.1016/s0300-9572(00)00334-8. View

19.

Mercier E, Giraudeau B, Ginies G, Perrotin D, Dequin P . Iatrogenic events contributing to ICU admission: a prospective study. Intensive Care Med. 2010; 36(6):1033-7. DOI: 10.1007/s00134-010-1793-9. View

20.

McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M . Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev. 2007; (3):CD005529. DOI: 10.1002/14651858.CD005529.pub2. View