(1249) Impact of Quality Peer Review of Intensive Care Unit Upgrades Within 24 Hours of Admission

Introduction: Patients admitted to a non-intensive care unit (ICU) and subsequently upgraded to an ICU within 24 hours of admission puts the patient, staff, and system at risk. An interdisciplinary review committee formed to systematically review these cases on a monthly basis. The committee standardized the evaluation, minimized the burden of the review process, and developed structural tools to monitor emergency department performance and support hospital operations to identify improvement processes. Initiatives were implemented upon review.

Methods: Each month, every upgrade admitted from one academic tertiary Emergency Department is identified, individually reviewed, coded through a standardized tool, and presented and discussed at the review committee meeting. The reason for upgrade (i.e. progression of disease, potentially preventable), primary diagnosis related to decompensation (i.e. sepsis, cardiogenic shock), and subsequent interventions required (i.e. invasive ventilation, vasopressors) are identified. The committee assigns a ‘standard of care determination’ and if not met, whether the gap or deviation in care was related to a systems and/or provider concern. Coded results of all monthly ICU upgrade cases are collated in a database and inform educational and quality improvement efforts. A inter rater kappa score was done in order to demonstrate reliability.

Results: To date, the committee has reviewed 119 cases over a one-year time frame. Of these cases, 43 (36.1%) were unanticipated progression of disease, 6 (5.0%) were related to missed diagnosis, 8 (6.7%) were related to missed treatment or disposition opportunity, and 13 (11.0%) were related to anticipated progression of disease with opportunity for earlier escalation of care. In total, 79 cases (66.4%) of the cohort met standards of care without opportunities for improvement. A kappa score demonstrated reliability in the process.

Conclusions: This is a high yield quality assurance exercise with 1 in 3 cases having a potential opportunity for improvement or educational opportunity on a system and/or provider level. The development of this robust quality assurance initiative continues to contribute to improvement interventions for safer and more effective patient care during the transition from a patient’s care in the ED to the ICU setting.