Patient Deterioration

The US Perspective

Sandy Gandee, MS, RN ACNS- BC

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Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

Mortality Amenable to Health Care

HEALTHY LIVES

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Patient Deterioration

The US Perspective

•The 2006 Institute of Medicine report Preventing Medication Errors recommended "incentives...so that profitability of hospitals, clinics, pharmacies, insurance companies, and manufacturers (are) aligned with patient safety goals;...(to) strengthen the business case for quality and safety.“

The Institute of Medicine (2006). "Preventing Medication Errors

Patient Deterioration

The US Perspective

•Driving Forces in US•IOM Report•Joint Commission•National Quality Forum•Centers for Medicare and Medicaid•Leap Frog•Health Grades•Private Insurance Contracts•Legal Liability

Early Recognition of the deteriorating patient

• Components necessary for early recognition– Nursing Expertise

• Knowing something is not as expected

– Knowledge of the patient• Caring for the patient on a continuum

– Knowledge of the patient through the family• Insight from the family as to whether the patient is

behaving as they normally would

Minick, P. and Harvey, S. The early recognition of patient problems among medical-surgical nurses, Medsurg Nursing, Oct. 2003, Vol. 12. No.5

Early Recognition of the deteriorating patient- Barriers

Nursing Expertise– Revolving Door Syndrome

• Med-Surg High Demand

• High Acuity• Lack of Specialization• Lack of Recognition• High Patient Care

Acuity• Increased patient ratios• Lack of Professional

Growth Opportunities

Early Recognition of the deteriorating patient- Barriers

Nursing Expertise– Knowing something is not

as expected requires• “Intuition” • Critical Thinking

– Need time to critically think

– Novice Nurses are task oriented

• Access to medical record– Less than 10% of US

hospitals have fully integrated EMR

– Need time to review • Confidence in decision

Early Recognition of the deteriorating patient- Barriers

Nursing Expertise

• Knowing something is not as expected requires– Vital Signs data

• Graphic record often times not kept at bedside

• Technical staff take vital signs

– Competency Assessment• Documentation in medical

record delayed• Automatic B/P machines

Early Recognition of the deteriorating patient- Barriers

Nursing Expertise• Vital Signs data

– Lack of Scoring Criteria• Mews?

– Lack of Knowledge• Nursing schools struggling with how

to teach critical thinking to novice nurses

• Respiratory rate and HR repeatedly shown to be an indicator for deterioration

• Treat confusion with PRN medications

Early Recognition of the deteriorating patient- Barriers

Nursing Expertise• Communication Skills

– We don’t have language to describe some of the subtle changes

– Novice nurses may be intimidated by some physicians

– Lack of rounding with Physicians– “It Depends”: Medical Residents

perspectives on working with nurses” Weinberg et al. AJN July 2009

– Challenges with SBAR (Situation, Background, Assessment, Recommendation)

“ I tell them tests that I need, butI don’t give them much information.They’re not making decisions aboutTreatment or anything” quote from “It Depends” by a medical resident.

Early Recognition of the deteriorating patient- Barriers

• Knowledge of the patient– Caring for the patient on a continuum– 12 hour shifts vs 8 hour shifts– Lack of access to medical record from previous

admissions– Chronically ill patients re-admitted to a variety of

units in same hospital– Assignments vary dependent on acuity– Unclear patient/family wishes regarding Do Not

Resuscitate Status

Early Recognition of the deteriorating patient- Barriers

• Knowledge of the patient through the family– Insight from the family as to whether the patient is

behaving as they normally would• Family may not be available• HIPAA

– Health Insurance Portability and Accountability Act• Health Care providers may not place needed value in

family information

Early Recognition of the deteriorating patient- Solutions for Nursing Expertise

• ALERT Course– Benefits

• Increase knowledge of nursing staff of s/s of deteriorating patients

• Simulation exercises enhance learning

• Expert users as a peer resource

• Enhance communication skills through role playing

• Decrease variability of expertise across system

• Eliminate routine vs being completed with b/p machines

• Ensure competency of technical staff

• Implement MEWS scoring system– Focus of education to include

communication of other assessment findings utilizing SBAR methods

– Place graphic data at bedside for nursing and physicians to evaluate trends

Early Recognition of the deteriorating patient- Solutions for Nursing Expertise

• Rapid review by clinical experts of mortalities to include identification of opportunities in:

– Failure to recognize– Failure to Plan– Failure to communicate– One-one debriefing with

staff• Encourage professional

growth opportunities in med-surg

• Implement Electronic Medical Record Systems

Early Recognition of the deteriorating patient- Solutions

• Knowledge of the patient– Hand–off communication at the Bedside

• Shift to shift• ED to units• PACU to units• Unit to unit (ICU-Med-Surg)

– Encourage assignments based on previous assignments as much as possible

– Clinical Nurse Specialist rounding for high risk patients– Evaluate need for 8 hour shifts vs 12 hours on some units– Implement electronic medical record system– Implement Order Sets which require physicians to

communicate what patient/family wishes are

Early Recognition of the deteriorating patient- Solutions

• Components necessary for early recognition– Knowledge of the patient

through the family• Involve patients family in

bedside report• Encourage family

attendance in Interdisciplinary Rounds at the bedside

• Open up communication lines with family members

– Ask patients to designate official spokes person for patient

Summary

“The Primary focus must be on process of systems based improvements versus a “sort

and shoot” reactive response.”Califorina Institue for Health systems Performance