PROJECT SUMMARY/ABSTRACT Unplanned ICU admissions from the acute care floor are common and most often related to the development of respiratory failure or cardiac dysfunction, with respiratory or circulatory impairment the reason for ICU admission in over 60% of cases. These admissions are associated with high morbidity and mortality and are accompanied by other important repercussions for patients and their family members, including inadequate communication and lower family ratings of care. Unplanned ICU admissions are strong indicators of adverse events, yet little is known about mechanisms underlying these admissions. Prior work has focused on patient characteristics associated with unplanned ICU admissions, including age and severity of illness, but there is limited evidence examining non-patient factors that also contribute, such as human (e.g., clinician), organizational, or technical failures. It is critical to understand how these non-patient factors affect unplanned ICU admissions, because admissions resulting from these factors may be preventable. It is also imperative to differentiate between non-patient factors (human vs organizational vs technical) and their associated mechanisms because they call for unique interventions. To fill this key knowledge gap, we propose to identify contributing factors and mechanisms for unplanned ICU admissions and connect these factors and mechanisms to patient- and family-centered outcomes. This objective will be met by achievement of three specific aims involving a cohort of patients transferred from acute care to the ICU at an academic medical center, a safety-net hospital, and a community hospital. The first aim will use root cause analysis to adapt and refine an existing framework for classification of adverse events, the PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) model. The adapted PRISMA model will allow us to identify multiple factors – patient, human (e.g., clinician), organizational, and technical — and associated mechanisms contributing to unplanned ICU admissions. The second aim will examine associations between factors and mechanisms contributing to unplanned ICU admissions and family member symptoms of psychological distress, including symptoms of depression, anxiety, and post-traumatic stress. The final aim will compare ICU-free days and costs of care across factors and mechanisms contributing to unplanned ICU admissions. Our team has extensive research experience with seriously ill patients and their family members, with expertise in development of interventions to improve patient- and family-centered outcomes, medical decision making, healthcare systems, and quality and safety. We are well-positioned to identify factors and mechanisms contributing to unplanned ICU admissions and generate the knowledge needed to develop interventions with the greatest potential to improve outcomes for patients, family members, and the healthcare system.

PROJECT NARRATIVE Unplanned ICU admissions from the acute care floor are common and associated with appreciable morbidity and mortality; despite these impacts, little is known about mechanisms underlying these admissions. The proposed research will address this knowledge gap by identifying factors and mechanisms contributing to unplanned ICU admissions and then connecting these factors and mechanisms to key patient- and family- centered outcomes. We will use this fundamental knowledge about unplanned ICU admissions to develop interventions to improve care for seriously ill patients and their family members.