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Causes and consequences of failure of implementation of management plans in critical care

Introduction

We investigated patient management plans to ascertain the total number made, types of plan, priority, personnel responsible and expected time frame, proportion completed and the causes and consequences of failed plans (on the patient, the family and the critical care service).

Methods

Over seven consecutive days, details of all consultant determined management plans were recorded by a dedicated nurse auditor. A plan was defined as an identifiable do-able, short-term action. Data on type, (arbitrary) priority, involved personnel and time frame were noted. The auditor later returned at the end of shift to determine whether plans had been completed in the appropriate time frame (successful plan) or not (unsuccessful plan). For unsuccessful plans, the nurse, senior nurse, senior house officer, fellow and consultant were all independently quizzed on causes and consequences (for patient, family, service) from a predetermined list of possibilities.

Results

Of 200 plans, 130 were successful, for three plans data were missing and 67 (34%) plans were unsuccessful. Of unsuccessful plans, 36 were completed late, 22 were never completed and nine had missing data. Thirty-six per cent, 34% and 18% of arbitrarily defined high-priority, medium-priority and low-priority plans were unsuccessful. Most plans were to be actioned by nurse or senior house officer, and 36% and 28% were unsuccessful, respectively. More unsuccessful plans than successful plans were recorded in the computerised notes, 79% vs 67%. Only 40% of data (staff opinions) on perceptions of causes and consequences were gathered. Patient consequences of failed plans included increased ICU stay in 24%, increased morbidity such as risk of inadequate nutrition in 9%, delayed definitive treatment in 7%, delayed weaning in 6%, increased risk of infection in 5% and no impact on patient in 44%. Consequences for family included no impact in 53%, misinformation given in 8%, delayed patient access in 2%, and delayed communication in 2%. Service consequences were bed blocking/increased workload in 20%, delayed admission of another patient in 14%, cancelled elective operations in 4%, and loss of unit capacity and cohesion in 7%.

Conclusion

We failed to achieve 100% successful plans. Small numbers and failure to gather more than 40% of staff opinions on causes and consequences of failed plans limit this pilot study. Documentation in (electronic) notes did not improve completion of plans. The process and efficiency of care has an impact on at least aspects of morbidity and length of stay, and deserve further study.

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El Toukhy, M., McQuillan, P. Causes and consequences of failure of implementation of management plans in critical care. Crit Care 11, P484 (2007). https://0-doi-org.brum.beds.ac.uk/10.1186/cc5644

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Keywords

  • Critical Care
  • Plan Data
  • Failed Plan
  • Expected Time
  • Successful Plan