Patient Deterioration
The US Perspective
Sandy Gandee, MS, RN ACNS- BC
HEALTHY LIVES
Mortality Amenable to Health Care
Deaths per 100,000 population*
2002/03
1997/98
150
134
130
116
109
99
100
88
81
76
84
88
50
77
74
74
71
71
65
115
113
97
97
89
89
115
106
128
80
82
84
84
82
90
93
96
101
104
103
103
110
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* 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).
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
“ I tell them tests that I need, but
I don’t give them much information.
nurses” Weinberg et al. AJN July 2009
– Challenges with SBAR (Situation, They’re not making decisions about
Treatment or anything” quote from
Background, Assessment,
“It Depends” by a medical resident.
Recommendation)
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 medsurg
• 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