3,936 research outputs found

    A Systematic Approach to Manage Clinical Deterioration on Inpatient Units in the Health Care System

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    The transformation of health care delivery in the United States is accelerating at unbelievable speed. The acceleration is a result of many variables including health care reform as well as the covariation occurring with adjustments in regulations related to resident work hours. The evolving care delivery model has exposed a vulnerability of the health system, specifically in academic medical centers of the United States. Academic medical centers have established a care delivery model grounded and predicated in resident presence and performance. With changes in resident work expectations and reduced time spent in hospitals, an urgent need exists to evaluate and recreate a model of care that produces quality outcomes in an efficient, service driven organization. One potential care model that would stabilize organizations is infusion of APNs with the expanded skills and knowledge to instill practice continuity in the critical care environment. A Medicare demonstration project is proposed for funding an APN expanded role and alteration in the care delivery model. Formative and summative evaluation and impact of such an expanded practice role is included in the proposed project. An evolved partnership between the advanced practice nurse and physician will serve to fill some of the gap currently existing in the delivery system of today. As the complexity and acuity of the patients in the hospital escalates, innovation is demanded to ensure a care model that will foster achievement of the quality outcomes expected and deserved

    Rapid Response Team Utilization of Modified Early Warning Scores to Improve Patient Outcomes

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    This retrospective, descriptive study was designed to (a) determine if the Modified Early Warning Score risk assessment tool identified moderate to high risk patients prior to the activation of the Rapid Response Team (b) determine how much time occurred from the onset of clinical deterioration until activation of the Rapid Response Team. A Modified Early Warning Score (MEWS) was applied to the documented vital signs in the medical records of a convenience sample of 108 adult patients between the ages of 19 and 99 years of age who had experienced an activation of the Rapid Response Team (RRT). A risk assessment score was given for the time of the RRT activation as well as every previously documented instance of vital signs prior to the RRT call until the MEWS score reached a low risk score of 0 to 1. Of the 108 subjects, 36 subjects had a low risk (score 0 to 1) MEWS at the time of the RRT activation; 72 subjects had a moderate (score of 2 to 3) or high (score 4 or greater) risk MEWS score at the time of the RRT activation. Ten (10.14) hours was the average amount of time earlier deterioration could have been detected if a MEWS system had been in place. The data from this study indicate a need for more frequent observation and documentation of vital signs by nursing staff as the overall average length of time between vital signs collected (MEWS applied) was 291.60 minutes (4.86 hours) when clinical deterioration was evident. These data show that there is a delay in activation of the Rapid Response Team and that implementation of the MEWS system would increase RRT awareness of patients with critically abnormal vital signs so that they can be assessed and clinical deterioration treated to prevent a catastrophic event from occurring

    Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

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    BACKGROUND: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. METHODS: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. RESULTS: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. CONCLUSION: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development

    Rapid Response Teams versus Critical Care Outreach Teams: Unplanned Escalations in Care and Associated Outcomes

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    The incidence of unplanned escalations during hospitalization is undocumented, but estimates may be as high as 1.2 million occurrences per year in the United States. Rapid Response Teams (RRT) were developed for the early recognition and treatment of deteriorating patients to deliver time-sensitive interventions, but evidence related to optimal activation criteria and structure is limited. The purpose of this study is to determine if an Early Warning Score-based Critical Care Outreach (CCO) model is related to the frequency of unplanned intra-hospital escalations in care compared to a RRT system based on staff nurse identification of vital sign derangements and physical assessments. The RRT model, in which staff nurses identified vital sign derangements to active the system, was compared with the addition of a CCO model, in which rapid response nurses activated the system based on Early Warning Score line graphs of patient condition over time. Logistic regressions were used to examine retrospective data from administrative datasets at a 237-bed community non-teaching hospital during two periods: 1) baseline period, RRT model (n=5,875) (Phase 1: October 1, 2010 – March 31, 2011), and; 2) intervention period, RRT/CCO model (n=6,273). (Phase 2: October 1, 2011 – March 31, 2012). The strongest predictor of unplanned escalations to the Intensive Care Unit was the type of rapid response system model. Unplanned ICU transfers were 1.4 times more likely to occur during the Phase 1 RRT period. In contrast, the type of rapid response model was not a significant predictor when all unplanned escalations (any type) were grouped together (medical-surgical-to-intermediate, medical-surgical-to-ICU and intermediate-to-ICU). This is the first study to report a relationship between unplanned escalations and different rapid response models. Based on the findings of fewer unplanned ICU transfers in the setting of a CCO model, health services researchers and clinicians should consider using automated Early Warning score graphs for hospital-wide surveillance of patient condition as a safety strategy

    Advance Alert Monitor

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    Problem: The acute deterioration of patients outside the Intensive Care Unit (ICU) are safety and quality concerns. Studies have shown that these deteriorations are associated with increased morbidity and mortality. This study aims to standardize the Rapid Response Team (RRT) nurse documentation in response to an Advanced Alert Monitor (AAM) alert, as at baseline no such alert nor standardized response and documentation exist. Context: Hospitals are continually challenged to innovate and create systems that can track multiple parameters and identify at-risk patients earlier on. An Early Warning System (EWS) in combination with a RRT significantly reduces patients’ potential for clinical decline. Predictive analytic systems such as an EWS are being introduced in response to this challenge and are anticipated to become the standard of care. The healthcare system/organization examined in this study aims to provide high quality, affordable health care services; and to improve the health of its members and the communities it serves. The Advance Alert Monitor (AAM) program enables this healthcare system/organization to better deliver on that mission by closing the quality gap of failure to recognize clinical decline in patients’ conditions. Interventions: The health system’s EWS is the AAM program. Its goal is to address safety and quality concerns associated with failing to identify a decline in patients’ conditions in a timely manner. The electronic health record and other sources are scanned constantly to generate an AAM score hour. If the score is eight percent or greater risk of deteriorating within 12 hours, E-Hospital staff review the patient’s chart and notify the RRT nurse. The RRT nurse collaborates with the primary nurse to assess the patient and communicate findings to the attending hospitalist. A standardized RRT nursing note is utilized to document the response for all initial AAM alerts. Measures: A family of measures was developed for the project. The outcome measure focused on the percentage of RRT nursing notes present for all initial AAM alerts. This measure recorded both a response and documentation of that response to the alert. Process measures included RRT proactive rounding documentation, and training of 100% RRT nurses on the AAM workflow. Tracking of code blue events outside the ICU was used as a balancing measure. Results: From January 1through June 30, 2018, there were 527 initial AAM alerts. Of those, 504 (95.6%) initial AAM alerts had the RRT nursing note present which indicates an intervention was made. Conclusions: The aim of this project was to integrate AAM predictive analytics with RRT practices that include a newly implemented standardized RRT nursing note; with AAM enabling early intervention to prevent a decline in patients’ conditions, and the RRT nursing note the documentation of such. The project was successfully implemented at the medical center with 95.6% RRT nursing note completion - and thus an intervention made - for all initial AAM alerts

    Postoperative Remote Automated Monitoring:Need for and State of the Science

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    Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented

    Introduction of a Comprehensive Modified Early Warning Scoring System in a Large Rural Hospital

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    PURPOSE: To develop and test a comprehensive modified early warning scoring (MEWS) system for use on two medical-surgical-telemetry units in a large rural hospital in northeastern Kentucky; to educate and train nursing staff in utilization of a new MEWS system and early identification and management of clinical deterioration; and to determine nursing satisfaction regarding education, training, and use of a new MEWS system. BACKGROUND: Adult medical-surgical patients are at risk for clinical deterioration. Rapid response systems and MEWS systems are strategies that have been employed to assist nursing staff in early identification and management of clinical deterioration. Testing of a newly proposed comprehensive MEWS system and an educational intervention is an essential first step in determining interventional effectiveness. STUDY DESIGN: A retrospective, single center, mixed methods observational study. METHODS: In Phase I, retrospective chart reviews (RCRs) were conducted during a 6-month timeframe for patients meeting one of the following severe adverse event (SAE) criteria: in-hospital cardiac arrest, in-hospital death, unexpected transfer to the intensive care unit, and/or rapid response team utilization specifically pertaining to the medical-surgical-telemetry units of interest. Physiologic parameters (i.e., vital signs and level of consciousness) and nursing responses were recorded in the 24-hours leading up to SAEs; MEWS were retrospectively calculated at 24-hours (MEWS24), 16-hours (MEWS16), and 8-hours (MEWS8) to gauge utility of the MEWS tool. In Phase II, a 3-hour education and training workshop designed for nursing staff was developed, implemented, and evaluated. A focus was placed on use of a new MEWS system and early identification and management of clinical deterioration. RESULTS: In Phase I of RCRs, 81 patients met criteria during a study timeframe of September 2016 through February 2017. Demographic data yielded the following: 51.9% male, 76.5% sixty years of age or older, and 98.8% White. MEWS24 (n = 62) had a mean of 3.0, standard deviation (SD) of 1.6, and range of 1.0 – 7.0; MEWS16 (n = 76) had a mean of 3.3, SD of 1.3, and range of 1.0 – 7.0; and MEWS8 (n = 81) had a mean of 5.0, SD of 2.3, and range of 1.0 – 10.0. In Phase II, nine nursing staff participated in one of eight education and training workshops. Participants reported increased confidence in recognizing deterioration, responding to deterioration, and communicating concerns following an educational intervention. Nursing staff consistently reported respiratory effort, level of consciousness, oxygen saturation, respiratory rate, blood pressure, and heart rate as the most influential parameters in a nursing assessment for determining clinical deterioration. Satisfaction was high regarding the education, training, and use of a new MEWS system. CONCLUSION: RCRs indicated that a MEWS system would be feasible in identifying patients at risk for SAEs in this patient population. Introduction of a new comprehensive MEWS system with an educational intervention had a positive effect on nursing staff’s self-reported confidence, knowledge, and skill in recognizing and managing clinical deterioration. RELEVANCE TO CLINICAL PRACTICE: Before full implementation, a prospective study is recommended to test a comprehensive MEWS system for all admissions through discharge over a defined time period and provide a mandatory educational intervention for interdisciplinary staff on the two medical-surgical-telemetry units of interest. Great insight could be learned regarding tool utility, resource utilization, and staff preparedness
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