A collaborative system to improve compartment syndrome recognition.
OBJECTIVE
Acute compartment syndrome (ACS) is a rare but serious complication of extremity injury that can cause permanent damage or death. ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant morbidity. Our objective was to create a reliable system for recognition of patients at risk and monitoring for ACS that could withstand frequent provider turnover.


METHODS
Using the Model for Improvement, we identified key drivers and failure modes for 2 processes: resident and nurse practitioner proper order entry and bedside nurse proper documentation of monitoring. Interventions were tested in frequent plan-do-study-act cycles. Effective interventions were used in combination to test for sustainability.


RESULTS
Proper order entry increased from 23% at baseline to 90%. Proper documentation for patients with correct orders increased from 15% to 70%. Individual interventions, including pocket card distribution, electronic medical record order set, and direct discussion by team leaders, were associated with improvement among residents but were not sustained with team turnover. Incorporating all 4 individual interventions into the on-boarding process for residents produced consistent success. Nursing documentation improved with education and maintenance of proper order entry.


CONCLUSIONS
We built a reliable, sustainable system to recognize and monitor patients at risk for ACS. Interventions designed to minimally disrupt existing workflows were individually associated with improvement. We achieved sustainability through staff turnover when we incorporated the interventions into routine orientation for new staff. Hospitals can use existing orders and protocols to sustain surveillance for ACS and other acute conditions.
Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 9016, Cincinnati, OH 45229-3039. joshua.schaffzin@cchmc.org.
Joshua K
JK
Schaffzin
Heather
H
Prichard
Jennifer
J
Bisig
Peggy
P
Gainor
Krista
K
Wolfe
Lauren G
LG
Solan
Laurie
L
Webster
James J
JJ
McCarthy
D000046:Academic Medical Centers / Q000458:organization & administration; D000208:Acute Disease; D002648:Child; D003161:Compartment Syndromes / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D004509:Education, Nursing, Continuing; D005121:Extremities / Q000293:injuries*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric / Q000458:organization & administration; D006801:Humans; D007396:Internship and Residency; D017146:Models, Organizational; D009722:Nurse Practitioners / Q000193:education; D009820:Ohio; D016530:Orthopedic Nursing / Q000193:education; D009985:Orthopedics / Q000193:education / Q000458:organization & administration; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000458:organization & administration; D058996:Quality Improvement / Q000458:organization & administration*; D012189:Retrospective Studies; D018570:Risk Assessment; D014947:Wounds and Injuries / Q000150:complications*
compartment syndrome; injury prevention; orthopedics; quality improvement; reliability science