Refinement of a Structured Intensive Care Unit (ICU) Dismissal Checklist to Prevent Unplanned Readmissions to a Surgical ICU

Abstract

PURPOSE: Quality improvement (QI) has become an integral part of critical care, particularly as the American Board of Internal Medicine has recognized this as a necessary component of recertification and therefore part of professional practice[1]. Readmission rates to an ICU are used as an indicator of quality, both for the ICU and institution [2]. Thus, a QI project on reducing unplanned readmissions was initiated. METHODS: A pilot discharge communication tool was implemented within a surgical ICU at a tertiary care center to improve communication between ICU providers and floor staff. The data indicated a trend toward improvement but had a low overall compliance rate. Plan-Do-Study-Act (PDSA) cycles indicated that the tool was labor-intensive. Therefore, a survey was designed to address which aspects of the tool should be modified. Unfortunately, the survey yielded no consensus on major revisions. Given the survey data, the checklist was simplified based on rapid-response team call criteria (which accounted for approximately 34% of readmissions per benchmark data), and a new dismissal checklist tool was drafted. Prior research has indicated that a checklist approach may be successful [1]. The new checklist was reviewed with ICU-stakeholders including nurses, residents, fellows and staff prior to implementation. RESULTS: PDSA cycles were completed regarding compliance with the revised checklist. Initially, there was 0% compliance due to confusion on how to correctly respond, despite multiple prior reviews. A second draft, along with repeat inperson education, resulted in improved compliance. A follow-up survey of residents indicated that despite changes, a paper checklist remained burdensome in a busy ICU and did not fit into the general workflow of the unit. CONCLUSIONS: Despite literate supporting successful utilization of dismissal checklists, paper checklists may no longer be the ideal method for quality improvement. This may be particularly true in busy ICUs that operate nearly entirely on electronic devices.