P2.281: Improving Pediatric Intensive Care Unit (PICU) to Pediatric Hospital Medicine (PHM) transfers

Purpose/Objectives: Patient flow is critical to achieving safe, timely, and efficient patient care. Our hospital has sometimes experienced a shortage of acute care beds; Pediatric Intensive Care Unit (PICU) patients who no longer require critical care but still need hospitalization become pending transfers. Daily handoffs were made for transfers to Pediatric Hospital Medicine (PHM), but handoff was not always safe or timely since it could occur several hours prior to transfer. Our objective was to improve the efficiency and timeliness of PICU to PHM patient handoffs.

Design/Methods: A multidisciplinary team developed a swim lane (Figure 1) to represent our current state. With this understanding of the overall system, we changed the transfer process by having the PICU place a transfer order prior to PHM acceptance. After a bed was assigned, PICU to PHM handoff occurred—indicated by pushing a “ready to move” button in Epic. Nursing handoff occurred after the patient was “ready to move”; it previously occurred as soon as a bed was assigned. Changes were made in Epic to support this change in the nursing process, such as a banner on Patient Story.

Our outcome metrics were time from handoff to patient movement and provider time saved. Our “pre” data was from a full year prior to our process change to account for seasonal variability; our post data is the first month since our process change. A balancing metric was the patients who arrived to acute care without handoff as reported in our safety event system.

Results: We had 450 PICU to PHM transfers in our pre data. Our baseline data showed that the median time from handoff to patient movement was 182 minutes (Interquartile range [IQR] 127-302); our average time was 403 minutes, indicating right skew. Fifty transfers had a time from hand-off to patient movement of greater than 18 hours, which likely required two daily handoffs. We estimated 8 minutes for an average handoff phone call; based on this, we saved PICU and PHM providers 400 minutes ( ~6.7 hours) each in handoff time.

Since our process change, our median time from handoff to patient movement was 42 minutes (IQR 23-65). We have had ~2 no calls per month for our balancing metric.

Conclusion/Discussion: We were able to utilize a staffing change to reevaluate our process for PICU to PHM transfers, with the goal of making them timelier and more efficient without compromising patient safety. We have achieved our timeliness and efficiency goals but still have improvements to make to reduce our “no calls.” Given that education is the lowest level of reliability, we are focusing on what system and electronic health record system changes we can make to support our bedside staff in this new process.