Establishing and Improving the Use of a Standardized Medical ICU Order Set in Osceola Hospital

From the 2023 HVPA National Conference

Sesha Sai Kanakamedala MD (a. University of Central Florida College of Medicine/HCA Florida Healthcare, Greater Orlando, Florida  b. Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida), Suhail Saad-Omer MD, Ernesto Munoz Pena MD, Aarushi Varshney DO, Ramzy Daoud MD, Alexander Kong MD, Tristan Tanner MD, Joshua Shultz MD, Ashwini Komarla MD

The intensive care unit (ICU) is one of the sites in which medical errors are most likely to occur due to the complexity of care thus necessitating a standardized admission process. Multiple studies suggest that standardized order sets reduce hospital length of stay, mortality, and medication errors. Given this, our group worked to design an updated ICU admission order set and promote its use to improve both patient care and staff satisfaction.

Multiple imperative orders were being missed on admission and transfer of patients to the ICU due to providers not using a standardized and comprehensive ICU admission order set. Between September 2022 and October 2022, we found that 9% of patients were missing code status, 34% were missing DVT prophylaxis, and 40% had no bowel regimen ordered. In addition to this, 70% of ventilated patients had no intubation order and 15% had incorrect ventilator settings orders at the time. Not only did this lead to compromised patient care, but resident and nursing satisfaction was also found to be affected. Only 29% of residents were satisfied with the current ICU order set, and nursing staff rated their current level of satisfaction with the ICU admission process at 6.8/10.

-Our aim was that by March 2023, the new standardized medical ICU admission order set would be utilized in at least 50% of all ICU admissions at HCA Florida Osceola Hospital.
-We aimed to increase the nursing satisfaction with the final process of at least 8/10.

Data including missing orders was analyzed over time pre and post intervention. We tracked this in a chart as we carried out interventions. Surveys were conducted to assess provider and nursing satisfaction pre- and post-intervention.

Our new ICU order set improved both nursing and resident satisfaction with nursing satisfaction increasing from 6.8/10 to 8/10 and resident satisfaction increasing from 29% to 70% between December 2021 and February 2023.  We also noticed a decreased rate of missing orders. Random spot checks post intervention from December 2022 to February 2023 showed that 100% of ICU patients had both code status and DVT prophylaxis orders placed while the number of patient’s lacking bowel regimens decreased from 40% to 15%. The rate of patients without initial intubation orders decreased from 70% to 45% with percentage of incorrect ventilator orders decreasing from 15% to 10%. These improvements also led to a decrease in the number of calls to the medicine intern.

We believe the key to these results was the continuous engagements we had with both residents and nurses in the form of announcements and flyers to help encourage consistent use of the new ICU order set. We hope to continue talking with both residents and nurses to determine any additional orders that need to be added and to encourage ICU order set usage. In order to help sustain our results, we plan on continuing to monitor number of missing orders periodically to help assess for any noted increase in missing orders set that would indicate a decrease in ICU order set usage.

Clinical Implications:
We demonstrated that improving the comprehensiveness of a ICU admission order set and promoting its consistent usage led to more complete care for critically ill patients, improved resident and nursing satisfaction, and fewer calls to providers. 

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