PM2062: Arriving Safely: Decreasing Rapid Escalations in Care for Incoming Transported Patients

Purpose/Objectives: Accurate inpatient placement for the level of care needed can be challenging. Incoming transported patients can present additional challenges, including illnesses in which the clinical status can change rapidly or experiencing a delayed arrival due to the distance traveled or unavailable transport crews. Rapid escalation in care following admission to the general inpatient unit for patients with acute deterioration has been associated with increased mortality. The Pediatric Early Warning Score (PEWS) system is useful for early recognition of clinical deterioration. This quality improvement project aimed to implement a PEWS system and escalation algorithm with 80% of incoming transported patients having PEWS completed during transport within 6 months.

Design/Methods: Stakeholders were gathered. An escalation algorithm was created utilizing the PEWS scoring system (Figure 1). The Model for Improvement was utilized testing interventions through PDSA cycles. Patient transport crews were taught the PEWS scoring system. Audit and feedback were used to increase the adoption of the new process. The number of rapid escalations was tracked and defined as transfer to the intensive care unit (ICU) or intermediate care unit (IMC) within 6 hours of admission.

Results: PEWS score completion by transport crews increased from a median of 45% to 75% (figure 2). This varied, however, by crew level of care with a low of 17% for the basic life support crews and a high of 79% completion rate for our local transport team. 11% (n=114) of PEW scores required physician notification and 20% (n=23) of these resulted in changes of interventions en route. Patients requiring rapid escalation in care remained below 2% each quarter. Upgrades were attempted during transport for 25% (n=3) of patients with rapid escalation in care, but were too close to adjust arrival location (n=2) or were denied by the accepting physician (n=1). 74% (n=14) of rapid escalations occur on night shift and 64% (n=9) of those occur after midnight. 58% (n=11) are transferred for increased respiratory support needs and 32% (n=6) for management and monitoring of neurologic issues.

Conclusion/Discussion: This project achieved improvement in PEWS completion and maintained a low rate of rapid escalations of care among incoming transfers. However, we fell short of our goal of 80% of transported patients with PEWS completion. Notably, some crew members report improved communication between transport crews and hospital providers and feel more empowered to speak up when a patient’s assessment was not as expected after the algorithm implementation. The next steps will include the investigation of barriers by crew level of care and reviewing communication between sending and receiving providers.