Improved clinical outcomes combining house staff self-assessment with an audit-based quality improvement program

Abstract

BACKGROUND: There is a focus on integrating quality improvement with medical education and advancement of the American College of Graduate Medical Education (ACGME) core competencies. OBJECTIVE: To determine if audits of patients with unexpected admission to the medical intensive care unit using a self-assessment tool and a focused Morbidity and Mortality (M&M) conference improves patient care. DESIGN: Charts from patients transferred from the general medical floor (GMF) to the medical intensive care unit (ICU) were reviewed by a multidisciplinary team. Physician and nursing self-assessment tools and a targeted monthly M&M conference were part of the educational component. PARTICIPANTS: Physicians and nurses participated in root cause analysis. MEASURES: Records of all patients transferred from a general medical floor (GMF) to the ICU were audited. One hundred ninety-four cases were reviewed over a 10-month period. RESULTS: New policies regarding vital signs and house staff escalation of care were initiated. The percentage of calls for patients who met medical emergency response team/critical care consult criteria increased from 53% to 73%, nurse notification of a change in a patient's condition increased from 65% to 100%, nursing documentation of the change in the patients condition and follow-up actions increased from 65% percent to a high of 90%, the number of cardiac arrests on a GMF decreased from 3.1/1,000 discharges to 0.6/1,000 discharges (p=0.002), and deaths on the Medicine Service decreased from 34/1,000 discharges to 24/1,000 discharges (p=0.024). CONCLUSION: We describe an audit-based program that involves nurses, house staff, a self-assessment tool and a focused M&M conference. The program resulted in significant policy changes, more rapid assessment of unstable patients and improved hospital outcomes. © 2010 Society of General Internal Medicine.