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The team of nurses that work night shift working in the Intensive Care Unit developed a new template in the electronic health record that shows a change in condition along with the action that should be taken. The confidence of nurses in their ability to recognize and call the provider increased from thirty three to forty three percent from the beginning of the implementation until now.

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There have been many deaths that have occurred in the ICU due to lack of communication within the healthcare team and many night shift nurses lack the confidence to ask the provider on duty what intervention should be performed.

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Poor communication within the interdisciplinary team may lead to issues with patients getting the care that they need.

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-Only 33% of nurses felt like their opinion of patient decline was valued.
-73% of nurses were confident in their ability to recognize and help the patient during changes.

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This facility is a 864 bed hospital. The ICU was a closed
20-bed unit comprising 14 ICU beds and 6 step-down beds.
Staffing consists of 3 surgical residents for most of the day, occasional critical care coverage on nights, 1 PA available from 6pm to 6am, and a trauma surgeon on call 24 hours a day. The ratio of ICU patients to nurse were 2:1.

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The nursing leadership, medical director of the SICU, and a nurses came together to create a list of decompensation changes that is implemented in the eMAR along with actions to take.

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The night shift nurses had very little contact with physicians and decreased support of other nurses. Part of the new system included a rounding with the SICU attending, on-call resident, PA, and other nurses.

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The nurses were asked to provide their feelings before, during, and after the implementations based on their confidence level.

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• Moved to ICU from SDU?
• Respiratory distress with potential need for unplanned intubation or ventilatory support (BiPAP/CPAP)?
• Hemodynamic instability with potential need for cardiovascular support (eg, pressors, antiarrhythmics, defibrillation)?
• Cardiac arrest?
• Neurological changes (eg, suspected CVA, seizure, new onset paralysis)?
• Iatrogenic event: serious complications from medical interventions?
• Bleeding with potential for unexpected blood transfusion?
• Development of any clinical problem that may require an invasive procedure/operation?
• Suicide attempt?
• Death?
• Other:
• Intuitive suspicion (describe):
Vital signs or laboratory values of concern before and after deterioration:
Issue escalated to (name and position):
Did a provider come to the bedside to evaluate the patient?
Intervention ordered:
Escalation up chain of command necessary?
If escalated, name and position of person notified (please request cosignature):

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All of the staff nurses which was around 49.

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Mixed, most of the information is qualitative and based on how the nurses feel. However, the episodes of escalations that are reported are quantitative.

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16 cases of patient deterioration were reported for 14 patients. During this trial, nurses got the opportunity to include their intuition and three cases of this were evaluated by a physician.
88% of cases providers assessed the patients at the bedside and performed interventions.

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-57% Day-shift nurses believed that their opinions were valued
-43% of night shift nurses now believe that their opinions valued compared to 33% before the implementation

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By having the checklist that evaluates what they should do in certain situations along with rounds, the nurses have improved their level of confidence so less cases of interventions not being performed have decreased. This would be a helpful thing to implement in the ICU.

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This Quality Improvement is based on helping the nurses on night shift at an ICU.

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These nurses need to communicate in a timely way and feel confident in their ability to provide care along with using their team such as the physicians.

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Nurses feel more confident in their communication, more valued, and have a better understanding of what to report and when.

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The recommendation is that hospitals include this eMAR template to help guide ICU nurses and that rounds with the physician include night shift as well.

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Liu, et. al. (2022).
Improving communication and response to clinical deterioration to increase patient safety in the intensive care unit. Critical Care Nurse, 42(5), 33-43.