Quality Corner
Improving communication in the ICU using daily goals,☆☆,

https://doi.org/10.1053/jcrc.2003.50008Get rights and content

Abstract

Background: Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. Purpose: The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form. Design: We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form. Results: At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days. Conclusion: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine. © 2003 Elsevier Inc. All rights reserved.

Section snippets

Objectives

The specific aims of this article are to describe our efforts to evaluate the effectiveness of communication during daily rounds in the ICU and to improve communication through the use of a daily goals form.

Data sources and settings

This study was conducted as part of a collaborative effort between the Volunteer Hospital Association (VHA), the Institute for Healthcare Improvement (IHI), and an academic 16-bed surgical ICU to improve the quality of ICU care.

Study design

Patients in our ICU are cared for by an intensivist-led team that includes ICU attending physician and fellows, anesthesia and surgery residents, nurse practitioners, nurses, and a pharmacist. During each month there are 3 residents, who rotate monthly, and 3 nurse practitioners caring for patients in the ICU. During daily rounds, the ICU team visits each patient for about 20 to 25 minutes and develops a plan of care for the day, discussing evidence regarding diagnosis or therapy and developing

Data collection methods

The authors developed a survey to evaluate the extent to which team members understood the goals of therapy. To estimate the magnitude of the communication problem, the physician-researcher (P.P.) asked the ICU residents and nurses the following 2 questions after rounds: (1) How well do you understand the goals of care for this patient today? and (2) How well do you understand what work needs to be accomplished to get this patient to the next level of care? The response categories for each

Analysis and interpretation

The analysis is descriptive. We used a run chart to display LOS and the percent of residents and nurses who stated (scored 4 or 5) that they understood the daily goals and tasks for each patient before and after the intervention.

Results

During the first 2 weeks, less than 10% of residents and nurses understood the daily goals of therapy and the daily tasks to be completed. After implementing the goals form (Fig 1), the percent of residents and nurses who understood the daily goals increased to over 95%.

. Percent of residents and nurses per week understanding goals.

Because the score for the question regarding goals and daily tasks were nearly identical, we present the goals data. The scores for residents and nurses were similar

Conclusion

At the start of the study, few residents or nurses understood the daily goals of care for patients in the ICU. After implementing the daily goals form, however, nearly all residents and nurses understood goals for the day and use of the form was associated with a 50% decrease in ICU LOS. This study did not evaluate how the use of the goals reduced LOS. Nevertheless, similar to personal effectiveness or project management tools, stating clearly the tasks, care plan, and communication plan to be

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Supported in part by a grant (U18HS11902-02) from the Agency for Healthcare Research and Quality (P.P.); and a grant (K23HL70058-01) from the National Heart, Lung and Blood Institute (S.B.).

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Address reprint requests to Peter Pronovost, MD, PhD, Associate Professor, Departments of Anesthesiology & Critical Care Medicine, Surgery and Health Policy & Management, The Johns Hopkins University, 600 N. Wolfe St, Baltimore, MD 21287; e-mail: [email protected].

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