Patient Safety Tip of the Week
December 29, 2009 Recognizing Deteriorating Patients
“Failure to rescue” is becoming one of the recurrent themes we see in patient safety evaluations in acute care settings (and some more chronic settings, too). We’ve previously done several columns on responses to clinical deterioration and use of rapid response teams (see our What’s New in the Patient Safety World columns for August 2007 “Responding to Patients with Clinical Deterioration”, December 2008 “Rapid Response Teams Don’t Live Up to Expectations”, and April 2009 “Early Emergency Team Calls Reduce Serious Adverse Events” plus our November 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams”). The impact of rapid response teams on actual outcomes has shown mixed results.
Whether or not you believe that rapid response teams have a significant impact on patient safety, there is one unmistakable fact: we need to do a better job of recognizing earlier the patient who is deteriorating and initiating appropriate responses. When you do your root cause analyses on serious events, it is not uncommon to identify cases in which earlier recognition and action on a deteriorating patient might have prevented an adverse outcome. Also, those organizations that have done detailed reviews of all patients undergoing cardiopulmonary arrests or patients requiring transfer to ICU’s typically find that more subtle deterioration had preceded the formal event in the majority of cases.
In our April 2009 What’s New in the Patient Safety World column “Early Emergency Team Calls Reduce Serious Adverse Events” we noted that reanalysis of the data from the MERIT study (Medical Emergency Response Intervention and Therapy) found evidence to support the concept of the early emergency call (Chen et al 2009). They found that early calls were associated with reductions in the rate of cardiac arrests and unexpected deaths. For every 10% increase in early calls, there was a 2.2 per 100,000 reduction in cardiac arrests and a 0.94 per 100,000 reduction in unexpected deaths.
The National Patient Safety Agency (UK) had reported in 2007 that 11% of deaths analyzed in one year were the result of deterioration not recognized or acted upon. Some incidents involved cases where no vital sign observations were made for prolonged periods but more frequently vital sign observations were made but the significance of the trends were not appreciated. And in yet others, the significance was recognized but there was a delay in the medical response.
One of the UK’s Patient Safety First campaign’s projects “Reducing Harm from Deterioration” is based on that 2007 report and the 2007 NICE (National Institute for Health and Clinical Excellence) clinical guideline “Acutely ill patients in hospital. Recognition of and response to acute illness in adults in the hospital”.
The intervention used in “Reducing Harm from Deterioration” consists of 6 key elements:
- Physiological observations should be recorded on all patients
- These observations should be recorded by staff trained to understand their clinical relevance and act upon them
- Physiological track and trigger systems should be used
- You should have a graded response strategy
- An escalation protocol should be in place
- A good communication tool should be utilized
Most of you will say “of course we
record physiological observations on all our patients”. And you undoubtedly do.
However, if you do chart audits you will often find things like respiratory
rate missing. Worse yet, when you see 8 straight recordings of respiratory rate
as “20” you can probably guess that there has not been accurate recording of
the respiratory rate!
One of the problems we are seeing now is an unintended consequence of computerization. In the past, when nurses recorded vital signs they did so on a flow chart where trends were readily discernible. Today, they are often entering those vital signs into an isolated computer screen and the flow chart may not be readily visible. Say, for instance, that the respiratory rate is 24. In isolation, that respiratory rate might not raise concern. But if you saw a trend where the respiratory rate began at 16 and increased by 2 breaths per minute each hour, then the rate of 24 should definitely raise concerns. Today’s hospital electronic medical records often do not mimic the old vital sign graphic chart. Yes, you may be able to get to some sort of representation of vital signs that allows trends to be seen but that often takes several clicks to get to and it’s often not even a graphic representation. More importantly, it is often lacking when the nurse is at the patient’s bedside. Result: an opportunity to detect patient deterioration early is missed. Therefore, it is critical that you build into your EMR the capability of displaying the vital sign trends while new data are being input. Alternatively (or in addition) you may develop computer algorhithms that are designed to detect such trends and alert accountable individuals.
Making sure that the physiological observations are recorded by staff trained to understand and act upon them is not as easy as it sounds. Many facilities today have vital signs recorded by someone other than RN’s (or they may even be recorded mechanically). In such cases, it is crucial that a nurse be available to promptly review those results.
There are a variety of track and trigger tools but the best known is probably MEWS (modified early warning score). That is a system that utilizes physiological parameters to calculate a “score” that helps identify patients with subtle signs of deterioration. But you need to keep in mind that MEWS was developed as a general tool and may not be applicable to an individual patient. For example, you may need to take into account that one of the individual patient’s baseline parameters is not “normal”. If a patient’s baseline blood pressure is 160/100, a new blood pressure measurement of 140/80 could be an easily missed sign of early deterioration.
Some facilities color code the MEWS scores. For instance, they may use green to indicate that the score is in the “normal” range, yellow for scores moving outside the normal range, and red for scores clearly in the abnormal range. Some facilities even use these colors (or some other sort of alert icon) on the computerized status boards or on whiteboards in the nursing stations.
There is an excellent article on MEWS in this month’s Joint Commission Journal on Quality and Patient Safety (Maupin et al 2009). The Mercy Hospital system in Cincinnati had noted failure to rescue as a common theme in many of their root cause analyses. They then did a chart review on a year’s worth of Code Blues and found that in 60% of the cases application of MEWS could have led to earlier recognition of patient deterioration (by an average of 6.6 hours prior to the code). The article goes on to describe how they went about piloting and implementing MEWS in their system and the dramatic improvements they achieved (substantial reduction in number of Code Blues and increase in the number of calls to the rapid response teams). Implementing the MEWS, which was facilitated by their IT system, required very little additional time on the part of nurses. Their project was so successful that they are now implementing “outbound” MEWS, i.e. applying MEWS to patients as they leave the ER for an admission to the floor or as they leave ICU! Definitely a good read. Also nice description of the MEWS tool and good quality improvement project management.
The previously mentioned NICE guideline also discusses several scoring systems for identification of patients clinically deteriorating, including the MET (single parameter), MEWS (aggregate scoring system) and ASSIST (assessment score for sick patient identification and step-up in treatment – aggregate scoring system) systems.
Note also that your tracking and trigger tool may be customized for different areas of care. For instance, you might have different versions for obstetrical patients, pediatric patients, and adult medical/surgical patients.
The graded response strategy and escalation protocol typically consists of differing responses based upon the scoring of whatever track and trigger system you are using. For example, for those cases that hit your threshold for a response, the early response may simply be increasing the frequency of observation and notifying the charge nurse. The next level threshold might involve urgently notifying the medical team with primary responsibility for the patient. And the highest threshold would trigger a call to your rapid response team.
A good communication tool should be used to escalate concern between team members. Most such tools utilize the SBAR format but alternatives exist (eg. RSVP: Reason-Story-Vital Signs-Plan). The “How to Guide’ for Reducing Harm from Deterioration provides nice examples of both SBAR and RSVP format tools and a sample audit tool for evaluating your use of an SBAR tool.
The Patient Safety First campaign website contains multiple resources for addressing the issue of early recognition and intervention for clinical deterioration. In addition to the “How to Guide” for Reducing Harm from Deterioration there are several clinical case studies from UK hospitals that have implemented successful systems. One of the most interesting lessons from the case studies was that one hospital went back to the bedside sphygmomanometer for taking blood pressures manually (rather than using more automated systems for blood pressure recording). They found that this required face-to-face contact with the patient, facilitating use of other cues to more rapidly identify signs of deterioration. The “How to Guide’ for Reducing Harm from Deterioration also discusses measurements to determine the impact of your programs.
References:
Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S; MERIT Study Investigators for the Simpson Centre; ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009 Jan;37(1):148-53
National Patient Safety Agency (UK). Safer care for the acutely ill patient: learning from serious incidents. 2007
NICE (National Institute for Health and Clinical Excellence). Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. July 2007
http://www.nice.org.uk/guidance/CG50
Patient Safety First (UK). Interventions. Deterioration.
http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Deterioration/
Patient Safety First (UK). The “How To Guide” For Reducing Harm From Deterioration.
Maupin JM, Roth DJ. Krapes JM. Use of the Modified Early Warning Score Decreases Code Blue Events. Joint Commission Journal on Quality and Patient Safety 2009; 35(12): 598-603
http://www.ingentaconnect.com/content/jcaho/jcjqs/2009/00000035/00000012/art00006
http://www.patientsafetysolutions.com
Patient
Safety Tip of the Week Archive
What’s New in the Patient Safety World Archive