The NCID ICU Retrieval Protocol for intubated patients was established for safety of the intubated patient’s transfer following post code-blue or intubation. The protocol includes response time of within 15minutes on site to general ward by ICU Nurse along with required ICU equipment during transfer. After initiating the protocol, feedback from physician highlighted several practice gaps in the process. Response compliance rate by retrieval nurse was 46%. This led to a review of the service, with aims to improve compliance to NCID Protocol for retrieval of intubated patients by retrieval team from 46% to 100%. Using the CPIP methodology, top vital few root causes were identified and series of PDSA cycles were carried out to tackle on each root. The project had successfully increased the compliance rate to Retrieval Protocol of Intubated Patient by Retrieval Team from baseline median of 46% to 77% from Jul 2019-Feb 2020, and further sustained and improved to 100% as of Feb 2022.
