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Gaps in Documented Assessments at the Time of Intensive Care Unit Admission
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927769
ABSTRACT
RATIONALE During this unprecedented COVID-19 pandemic intensive care units (ICU) need efficient ways to deliver patient care. As hospital workload increases, so does the risk for medical error and delays in care. A systematic initial approach and timely documentation is important to provide an efficient and thorough assessment and to facilitate communication within the interprofessional team. We aimed to evaluate documentation of key assessment elements at ICU admission. METHODS The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is a validated tool that reduces errors in the initial assessment and ongoing care of critically ill patients. With Mayo IRB approval, electronic medical records (EMR) of a convenience sample of ICU patients admitted to medical, surgical and mixed ICUs at our institution during October 2021 were reviewed to assess documentation of the CERTAIN primary survey, including assessment of airway, breathing, cardiac, disability, and exposure (ABCDE);vital signs;intravenous access;point of care labs and ultrasound (POCUS);differential diagnosis;and plan by systems including code status and goals of care. Patients admitted for post-operative monitoring and those who declined the use of their medical records for research were excluded. RESULTS Forty patient EMRs were reviewed. Median age was 65 years, 47.5% were female, and respiratory failure was the most common reason for ICU admission. Documented frequency of airway assessment was 32.5%, breathing 92.5%, cardiac 70%, disability 42.5%, and exposure 85%. Thorough vital sign review including temperature was documented in 47.5% of ICU admissions. A comment or plan for intravenous or intraosseous access was documented in 75% of patients. Completion or review of same day point of care labs was documented in 55%. Cardiac POCUS was documented in 9 of 40 ICU admissions. No patients had documented lung or abdominal POCUS. 80% had a differential diagnosis documented as part of their initial assessment. All patients had a complete plan by systems. 85% of patients had a documented code status, although it was unclear if it had been actively re-addressed on ICU admission. CONCLUSION EMR documentation of key findings at the time of ICU admission leaves significant opportunities for improvement, with particularly large gaps in primary survey and POCUS assessment. The results of this study, combined with ongoing direct observation of ICU admissions using the CERTAIN checklist, will inform future recommendations to improve the performance and documentation of key assessment elements during the “golden first hour” of ICU admission.
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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: American Journal of Respiratory and Critical Care Medicine Year: 2022 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: American Journal of Respiratory and Critical Care Medicine Year: 2022 Document Type: Article