Abstract

We aimed to develop a team resource management (TRM) program that is logistically more efficient; we did so through the investigation of intrasystemic risk factors and through providing evidence-based support. We evaluated the program’s clinical effects on accidental catheter removal (ACR) in an intensive care unit (ICU) of a medical center. Before developing the TRM program, we used a 3-year ICU dataset to identify 46 patients and 48 events of ACR comprising 65.2% endotracheal tubes and 19.6% central venous catheters. Through an assessment of baseline characteristics,we observed the following intrasystemic problems: inadequate communication to patients, insufficient identification of high-risk patients, lack of chemical sedation for eligible patients, discordant ICU team workflow and cross-monitoring, and inadequate professional training. A problem-targeting, multifaceted TRM program was implemented in an ICU in April 1, 2019, following an estimation of its clinical effectiveness through systemic review and meta-analysis. The ACR incidence remarkably decreased after implementing the TRM program; five ACR cases in 2017, five in 2018, one in 2019, and two in 2020. In this study, we demonstrated a reliable strategy of TRM program development to reduce ACR in the ICU.