A collaborative system to improve compartment syndrome recognition

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 syst...

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Bibliographic Details
Published in:Pediatrics (Evanston) 2013-12, Vol.132 (6), p.e1672-e1679
Main Authors: Schaffzin, Joshua K, Prichard, Heather, Bisig, Jennifer, Gainor, Peggy, Wolfe, Krista, Solan, Lauren G, Webster, Laurie, McCarthy, James J
Format: Article
Language:English
Subjects:
Academic Medical Centers - organization & administration
Accident prevention
Acute Disease
Child
Compartment syndrome
Compartment syndromes
Compartment Syndromes - diagnosis
Compartment Syndromes - etiology
Compartment Syndromes - therapy
Diagnosis
Education, Nursing, Continuing
Extremities - injuries
Guideline Adherence - statistics & numerical data
Hospitals, Pediatric - organization & administration
Humans
Injuries
Internship and Residency
Models, Organizational
Nurse Practitioners - education
Ohio
Orthopedic Nursing - education
Orthopedics
Orthopedics - education
Orthopedics - organization & administration
Orthopedists
Outcome and Process Assessment (Health Care)
Patient Care Team - organization & administration
Pediatrics
Practice
Practice Guidelines as Topic
Prevention
Program Evaluation
Quality Assurance, Health Care - methods
Quality Assurance, Health Care - organization & administration
Quality Improvement - organization & administration
Quality of care
Retrospective Studies
Risk Assessment
Tissues
Wounds and injuries
Wounds and Injuries - complications
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Summary: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. 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. 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. 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.
ISSN:0031-4005
1098-4275
DOI:10.1542/peds.2013-1330