Preventing Early Bouncebacks to the Neurointensive Care Unit: A Retrospective Analysis and Quality Improvement Pilot

Abstract

Patients at high risk for bounceback after transfer from the neuro-ICU can be identified using a simple tool. Early augmented multidisciplinary communication and care for high-risk patients may improve their management in the hospital.

Standardized Transfer Process for a Neurointensive Care Unit and Assessment of Patient Bounceback

“…The written note itself might have been perceived as redundant documentation, and the compliance with this part of the process might have been limited. Moreover, providers were likely already performing some form of verbal handoff prior to the implementation of this process as part of prior work by Coughlin et al [ 9 ]. Although there was no significant improvement with provider-rated safety in terms of overnight transfers and verbal communication between nurses, the standardized transfer process did not directly intervene on these measures.…”

“…The framework for patient transfers created by Coughlin et al [ 9 ] included identification of high-risk patient transfers, verbal handoffs between providers, text alerts after patient transfers, and evaluation of patients on arrival. We built on this framework by standardizing each of these steps and adding additional steps that addressed the weakest areas of the transfer process on the basis of the preintervention survey.…”

“…We then conducted a retrospective analysis of patients who bounced back after transfer. Similar to the prior study by Coughlin et al [ 9 ], bounceback was defined as either an unplanned return to the neuro-ICU or an unplanned transfer from a floor bed to an intermediate critical care unit bed within 48 h of transfer from the neuro-ICU. We included all patients transferred to the neurology service and excluded patients from the neurosurgical services.…”

“…This initiative to create a standardized handoff for pediatric patients transitioning from the cardiovascular ICU to the acute care unit resulted in significantly improved transfer efficacy, safety culture scores, and satisfaction for both families and medical providers. In previous work at our own institution, Coughlin et al [ 9 ] created a standardized checklist known as a “green sheet” that identified neurology patients at high risk of bouncing back to the neuro-ICU. The sheet required providers to check risk factors a patient had that would increase their risk of bounceback to the neuro-ICU, including if they required intubation for more than 4 days, reintubation during admission, antibiotic changes, intravenous (IV) antihypertension medications, IV pressors, treatment of multiple seizures, or treatment of cardiac arrhythmias.…”

Communicating Neurocritical Illness: The Anatomy of Misunderstanding

“…Checklists may not reduce intensive care unit (ICU) readmissions or rapid response team calls [13]. The rapid readmissions or so-called bounce backs remain difficult to predict, and communication failure is just one factor [15,16]. Generally, inadequate communication leads to a diffused responsibility, and we will pay a price.…”