Strong indicators that telling nurses when to call the doctor to the bedside reduce bad outcomes.
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- Michael Howell, MD, MPH; Patricia Folcarelli, RN, PhD; Boston, MA
It's hard to argue with the logic:
"If you think about modern health care—at least in the inpatient setting—most of what we practice evolved rather than having been designed. And if you sit and think about the different processes that we have, when you design them you get much better results for the most part than if you just take what's evolved over the past 50 or 100 years."
It's hard to argue with the results:
"A patient who was admitted in 2004 was more than twice as likely to have one of these things that we consider a bad death, an unexpected mortality. They were more than twice as likely as they are today after we control for age, gender, co-morbidity season, etc."
At Beth Israel Deaconess Medical Center a program that requires a response to a patient whose status is changing for the worse has brought about care that is markedly better. And it has done this at an institution with a world-class reputation for patient care.
Dr. Michael Howell is Director of Critical Care Quality at Beth Israel Deaconess, and a co-leader for a quality innovation that uses objective clinical measures—called "triggers"—to trigger a call from a nurse to a doctor. The nurse uses the electronic ordering system to call a trigger when a patient's worsening condition meets specific criteria. This generates a note, which incorporates the last lab results for the patient and a list of the patient's medications. Once a trigger is called, the resident must go to the patient's bedside, and a respiratory therapist must come if the trigger is for a respiratory event. The resident and nurse write an interdisciplinary note; the resident calls the attending, and the nurse calls a nursing supervisor.
Pat Folcarelli has worked with Dr. Howell to implement the trigger program at Beth Israel Deaconess. Folcarelli is a nurse and the Director of Patient Safety. She describes the triggers that now require a nurse to call a physician.
"If the patient has a heart rate of less than 40 or more than 130, if the patient has a blood pressure of less than 90, if the patient's respiratory rate goes below 80 or above 130, if the patient has an oxygen saturation that goes below 90% with oxygen therapy, if there is a urine output of less than 50cc's in four hours, if there is an acute change in consciousness, or if there is marked nursing concern and these are intended to be for the acute new development of these."
They added a trigger for placement of a non-rebreather mask when they saw that nurses who were reluctant to call a trigger would sometimes apply higher and higher concentrations of oxygen therapy and not recognize a problem early enough. According to Folcarelli, the "marked nursing concern" trigger worried some physicians before the program was implemented. They thought it would be over-used for vague concerns. But it turns out it is rarely used, and when it is, the nurse is usually observing a real—if undefined—problem. If anything, they had to train some nurses to be more assertive:
"Sometimes the nurse would call and the conversation on the phone might go something like this; ‘Hello, Dr. Smith. I'm thinking of calling a trigger on Mrs. Jones because her heart rate is 40.' The doctor would say, ‘you know, don't call a trigger on her because I'll just come up and see the patient, or don't call a trigger on her, she always does that.' So, what we did was some education with the nursing staff around language choice and encouraged them to have a conversation that was more directive, that sounded like this: ‘Mrs. Jones has triggered. I'll meet you at the patient's bedside, or Mrs. Jones has triggered for a heart rate of 40.' Not, ‘I'm thinking of calling a trigger.'"
Dr. Howell says the outcome data they've gathered throughout the implementation of the trigger program is compelling, and initial resistance to it has gone down. It's hard to argue with the large drop in unexpected deaths. Dr. Howell says one unhappy attending became a convert to the trigger program in real time during a single case. The patient developed a fast respiratory rate.
"And the attending physician had made a plan for it, but something sort of … and everyone on the team knew it, but something subtly changed a little bit in the middle of the night. The patient got triggered for a fast respiratory rate again. The attending was really angry about being called about the trigger and actually sent me a note explaining how angry they were, and four hours later the patient had a cardiac arrest."
Another worry that residents had dissipated as well. They were concerned they would lose autonomy and no longer be managing patients who were acutely ill.
"And the irony of that is the model in most centers around the country—and "most" being something like 90 or 95 percent or more—is that the way that a rapid response team is implemented is: a patient gets sick and the nurse calls a rapid response team, which is an ICU-based team, totally different than the primary team. This special team comes and takes care of the patient, does some things to them, and then gives the care back to the primary team and that is very different than the model that we implemented where we rely on the primary team and we believe that the primary team is the best set of people to actually take care of the patient if they know them. So, that was one major group that needed convincing and over time in many ways now is the best advocate for triggers."
Use of the electronic ordering system has been helpful. But Dr. Howell says there's no getting around the fact that this usually means more work for the caregivers involved.
"It means that you have to go and see the patient. It means you have to talk to the resident. It means that you have to write a note and that one of you has to call your attending. And as much as we've tried to optimize that there is a certain amount of work that goes with the patient getting sick and we can't figure out a way to make it less. We can't figure out a way to make it less than saying, ‘okay, when you're called for a trigger go and see the patient, be a doctor, write a note, and talk to the attending.' Those are the core principles of what you have to do as a responder."
About the series
Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.