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Lukes Medical Center Global City

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PROJECT TITLE: ICU PEARLS: A Guide For ICU Hand Off

PROCESS / ACTIVITY:

PROJECT TEAM NAME: CRITI-GALES

AFFECTED QPS STANDARD: QPS 2.1

Correlation between ICU PEARLS Orientation and Utilization by Staff Nurses during Hand Off and Hand-off related Incidence Occurrence

PERFORMANCE MEASURE:
Hand-off related Incidence Occurrence in the Adult Critical Care Cluster

DATA SOURCES:

(List all evidences of performance e.g. reports, monitoring tools, etc.)

Aspects of Care Prioritization Survey Tool, Incidence Monitoring Tool, ICU PEARLS Satisfaction Survey

OPERATIONAL DEFINITION OF TERMS:

(Define terminologies and spell-out acronyms used.)

Hand Off Period bedside nurse endorsement between three shifts [6am to 2pm, 2pm to 10pm, 10pm to 6am] Aspects of Care 73 previously identified pertinent patient data and ICU nursing activities based on the following SLMC GC documents: ICU Flowsheet Upper Kardex Patient Profile and Medical Chart Incidence/Hand-off related Incidence: 5 identified types of hand off related incidents Detected Omission Callbacks to the Unit Medication Error or Lapses [e.g. physical counting lapse] Missed Documentation [e.g incomplete MTR/charting] Missed Follow-Ups/Diagnostics/Procedures

D E S I G N

Data that ranked as Low Level Priority: Score: 1 unnecessary to include in endorsement; the omission of which has no deleterious effect on patient status Data that ranked as Medium Level Priority: Score: 2 associated with patient status; the omission of which has no deleterious effect on patient status Data that ranked as High Level Priority: Score: 3 essential to patient status and survival that must always be included in bedside endorsement; omission of data may result in patient harm/death

FORMULA: Total number of incidences[prior] /Total survey period[prior] = 47 incidences/30 days = 1.57 incidence occurrence/day Total number of incidences[after]/Total survey period[after] = October1-October 7 2010 4 incidences/7 days = 0.57 incidence occurrence/day

TARGET VALUE/ THRESHOLD:

90% reduction in incidence occurrence over a 2-3 month period of implementation

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RESULT:

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REPORTING PERIOD: Weekly reporting period by Point Persons utilizing the Incidence Monitoring Tool FINDINGS / CONCLUSIONS:
The survey of endorsement content ranked the following top 10 data as high priority. Significant Events Critical Values Stat Procedures/Treatment/Operations TFR [Fluid Intake] Dose of Medication Hemodynamics/Secretions Airway Type Level of Care Name Chief Complaint/Diagnosis Given a 7 day observation period after the implementation of the ICU PEARLS there was a 0.57 incidence/day rate in the Adult Critical Care Cluster. Further observation is needed to verify the correlation of the ICU PEARLS and Incidence Occurrence Rate.

A
S S E S S

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RECOMMENDATION/S:
[ongoing observation]
L A N

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(Draw recommendation/s based from findings)

ACTIONS / FOLLOW-UP:

(State what actions have been taken up, being undertaken or to be taken up; include status, date implemented/target date)

I
M P R O V E

D
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TARGET DATE: November 30 2010 STATUS: Ongoing Observation DATE IMPLEMENTED: September 25 2010 September 30 2010 ACTIONS TAKEN: Bedside Handing Off Monitoring [ICU PEARLS Evaluation Form] to measure which aspects of care ranked as high priority are commonly omitted during actual endorsement Nursing Satisfaction Survey Form regarding the ICU PEARLS Day Started: October 1, 2010 Charge Nurse Incident Tracking Tool Day Started: October 1, 2010 Proposed Actions: Coordination with managers spot checks to ensure validation of endorsement quality using the ICU PEARLS [time outs during endorsement to reflect on the ICU PEARLS] Laminated mini ICU PEARLS on IDs of staff and on individual patient clip boards as a visual and concrete reminder of ICU hand off standards

Responsible Committee:Adult Critical Care Prepared by:

Maria Alyssa Yee Policarpio 10/7/201 0

Reporting Date:10/7/2010 Noted by:

(Date) OVERSIGHT COMMITTEES:

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