In the critical care setting, early recognition of clinical decompensation is imperative to trigger prompt intervention and optimize patient outcomes.

Local Problem

In a 20-bed surgical intensive care unit of an urban academic medical center, cases of clinical deterioration that highlighted opportunities to improve the communication process prompted a reassessment of health care provider roles and responsibilities.


A quality improvement initiative was implemented to enhance communication among intensive care unit clinical staff members, improve the timeliness of reporting clinical deterioration, and ensure implementation of timely, appropriate interventions to eliminate adverse outcomes.


Nurses were surveyed to determine their perceptions of communication and collaboration among providers. Education was provided that focused on familiarizing nurses with clinical conditions necessitating direct notification of the attending surgical intensivist and included review of a case in which escalation of care did not occur. Multidisciplinary rounds were expanded to engage night-shift nurses in clinical discussions and decision-making. A template was created to document episodes of escalation in the electronic health record.


Since implementation of the quality improvement interventions, no incidents of patient harm or death related to failure to escalate have occurred to date. A total of 16 episodes of escalation for clinical deterioration were documented in the electronic health record. Most nurses reported an increased level of confidence in understanding when to escalate concerns about clinical deterioration.


Implementing a multimodal program to empower nurses to escalate clinical concerns directly to the attending physician eliminated adverse events related to failure to escalate.

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