Content That Lev <3 Likes

Content That Lev <3 Likes

Lev <3, BSN, RN 40,664 Views

Joined Jun 3, '11 - from 'Another planet'. Lev <3 is a ED Registered Nurse. She has 'A few' year(s) of experience and specializes in 'Emergency - CEN, upstairs, troll bashing'. Posts: 2,519 (52% Liked) Likes: 4,669

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  • 2:21 pm

    Quote from Lev <3
    Most of the basic questions do relate to vital signs - however, there are many sub questions which would pop up to determine if there is a quick treatable reason to the changes in vitals signs and to determine if these are truly "danger signs" or just the patient's baseline. It uses more nursing judgement than just a computer program spouting out abnormal vital signs. It also incorporates urine output. A computer program would depend on a CNA documenting I&O in a timely fashion which as we know does not happen as frequently as it should in real life. Is is easier for the nurse to ask the patient if they have used the bathroom in the past 6 hours.

    I am all for better nurse to patient ratios, however it took California 20 years to get those ratios and that was in just one state!

    It is designed to take about 10 minutes or less to fill out once the nurse gets the hang of it. Like I said, some other form of "petty" documentation should be taken away before implementing this.
    I agree with your point in general.
    Yes, it did take a long, huge battle to win patient ratios in CA. However, remember this, we typically do not have CNA's nor LVNs in in-patient settings. I can't speak for the whole state, but in 20 years, Ive never worked in a unit that had more than 1 CNA period, who mainly "helped" with patient care on occasion and ran errands. My point is that even here, we are often overwhelmed based on acuity of the patients on the Med-Surg floors. I work PICU and often floated to Med-Surg. Patient ratios definitely did make things better, but not perfect. I believe in primary care for several reasons. However, an experienced LVN is often more estute than a new grad RN. Just saying, that having full responsibility for the patient is safer in that all the variables in their care is overseen, i.e. LOC, skin changes, urine output, etc...possibly getting safe patient ratios would not be as hard to accomplish based upon the fact that CA achieved it. Look into the stats ....maybe there is correlation to better outcomes that are demonstrated. Not sure. Just a thought.

  • 2:20 pm

    I feel like the Modified early Warning Score is a very helpful tool. We have to get our own shift vitals where I work and use it as part of our assessments. It is calculated using MEWs. This intervention has assisted me and others with catching that a patient's condition has changed. You can have the patient that may look okay (and you think you got it under control), but the MEws calls for a rapid response team to be called. They then determines to transfer the patient off the floor. When the score is a 3 or above, we do vitals every 2 hours, have to call the doctor, and inform the charge nurse. When the score is a 5 or above, we have to call the rapid response. It is very useful.

  • Aug 23

    I currently work in a PCU, so I guess this algorithm technically doesn't apply to me. In my hospital system, we have an "Early Warning Score" that automatically populates when vital signs and GCS are charted. A score of 0-2 is considered stable. If the score is 3-4, we need to chart some kind of intervention or acknowledgement of the vitals. Per policy, a score of 5 or above warrants calling a rapid response. However, our system allows for some degree of nursing judgement...obviously there are patients whose baseline vital signs or mental status keep them at a 5 or above, and there are patients with scores of 0 who have a sudden change or just don't look right, and in that case we call a rapid response anyway. Either way we need to document that we are aware of the score and then have the option to chart, "patient at vitals baseline," "patient at neurological baseline," "provider at bedside," etc. This system exists on our med surg and tele floors as well, so I think your algorithm would be a little bit redundant because it addresses a lot of the same things. Also, I feel like it would be very difficult to take the time to fill this out for each patient 6 hours into each shift, and if there is a problem at that point it may already be too late to intervene.

    BUT...having worked as a med surg nurse for 3 years, I definitely agree that there is an issue with failing to recognize early signs of deterioration on non-monitored units and I appreciate what you're trying to do! But from my experience, the main issue is definitely staffing. When I had 7 patients and a constant stream of discharges and admissions, there were times when a patient would not be assessed or even have eyes on them for hours. We rarely had CNAs on our med surg floors and if we did they were responsible for 25-30 patients on their own. It's literally impossible to be on top of every tiny change in status when ratios are that high. Another issue I think is experience...I know the hospital where I work has a very young staff, especially on 3-11 and 11-7. On my unit I'm the second most experienced RN, and I've only been working for five years. When I was first starting out, I would often ask a more seasoned nurse to take a second look at my patient if I had a bad feeling but couldn't pinpoint exactly what the problem was. Without experienced nurses to consult with or ask questions, it's hard for new grads to pick up on subtle changes. It's honestly a recipe for disaster in my opinion, and the only way to fix this problem is to push for better staffing, which will in turn lead to improved staff retention.

  • Aug 23

    Quote from Anna Flaxis
    What about experience; how many veteran nurses and new grads are there?
    This seems to be the biggest factor that our facility has identified in regards to patients deteriorating without being noted. We had a relatively high proportion of new grads (about a year ago we had somebody that had been a nurse for 5 months doing charge on a med-surg floor). There has been significant improvement as our facility wide level of experience has increased.

    We've recently instituted a family initiated rapid response to help reduce the number of code that occur outside of ED & ICU. It has not been implemented long enough to garner any data.

  • Aug 23

    Quote from HouTx
    Great thread with lots of thoughtful responses.

    A couple of thoughts for OP

    Its unwise to "jump to solutions" until you actually know what the problem is. In my consulting years, a lot of work involved reversing the superficial "improvements" that were implemented to solve problems - AKA, it seemed like a good idea at the time. My mantra became "Today's problems were yesterday's solutions". Don't fall into that trap.

    Look at the research being done on "missed nursing care", "failure to rescue" and "nursing surveillance".... there's a ton of evidence out there to inform your decisions. Better yet, start analyzing those near misses or nursing failures using a system like HFACS or a rigorous root cause analysis process to determine the systemic problems that may actually be the causative factors.

    I very much agree with you here.
    It is imperative to do some investigation as to why the problem occurs as well as search in the literature. This has led me to recommend solutions or action that was not obvious to me from just looking at a problem.

  • Aug 23

    Rapid response teams were created in order to address this, i.e. to get a team up there before the patient codes. If the RN and tech are doing hourly rounding then between the two of them this could be accomplished. Also, incorporating any family/visitors. Most hospitals allow anybody to call the RRT. The instances where I have seen patients fall through the cracks is when there is poor communication between the nurse and CNA, for example CNA doesn't chart vitals in a timely manner. Or people chart signs of deterioration such as changes in VS or LOC but don't do anything about it, which is really shocking, but it happens!

  • Aug 23

    I remember when I was working on a step down unit and had a patient in rapid afib. I had pushed adenosine twice and lopressor twice trying to break it. No go. Then they ordered a cardizem bolus and drip. Once I bolused the cardizem the patient started having long pauses, with one over 15 seconds. He would come out of the paused briefly broken, and go right back to rapid afib. I called a rapid at that time. I called an RRT at that time. Everyone came and chatted up my patient for a bit, who mostly felt fine. They looked at the monitor, which at the time showed afib at a rate around 140, and basically told me I should be able to handle this and walked away. They chalked up my strips showing the pauses as being when the adenosine was pushed, even though I told them the time didn't correlate and those pauses had been much short. The rapid response team hadn't even gotten to the doors of my unit yet when the monitor was red alarming asystole again and they all ran back to see his eyes rolling in the back of his head. The intensivist slapped the pacing pads on his chest quite quickly just as the guy was coming back, again in rapid afib.

    Having a rapid response team was a new thing at my hospital at that time. I remember how much I agonized about calling a rapid that day, and then how deflated I felt when they blew off the main part of my concern. Thankfully, our rapid responses go much better now.

    He ended up doing just fine later on amio and after getting a pacemaker placed.

  • Aug 23

    Great thread with lots of thoughtful responses.

    A couple of thoughts for OP

    Its unwise to "jump to solutions" until you actually know what the problem is. In my consulting years, a lot of work involved reversing the superficial "improvements" that were implemented to solve problems - AKA, it seemed like a good idea at the time. My mantra became "Today's problems were yesterday's solutions". Don't fall into that trap.

    Look at the research being done on "missed nursing care", "failure to rescue" and "nursing surveillance".... there's a ton of evidence out there to inform your decisions. Better yet, start analyzing those near misses or nursing failures using a system like HFACS or a rigorous root cause analysis process to determine the systemic problems that may actually be the causative factors.

  • Aug 23

    Quote from blondy2061h
    So the rapid response triggers are the same for everyone? I hope you have a dedicated rapid response team with a policy like this.
    Well, in some places they are officially the same. In two hospitals I worked before and in one I'd mentioned in my previous post Rapid Responce Team was to be called according to certain vitals' numbers and symptoms, whether they were baseline or not. If patient complained on chest pain, one had to write a long note and fill yet another checklist if the nurse deemed the pain not worthy rapid responce. On the other hand, I had recently to call Rapid Responce during my clinicals for patient with HR 80 (DDD paced), BP like 120/80 (two hours before 220/120) and RR of 12. All that was beautifully seen on monitor. Except that the patient had Cheyne-Stokes breathing and all other clinical symptoms of severe metabolic acidosis. I had to give them long explanation why I needed them there STAT because vitals were ok.
    Even worse, once they are there, they just feel obliged to do something. During that memorable night they were called THREE times because my BP below 90, no other symptoms save for itching and wheezing which were expected. Three times I had to refuse CT scan ("but it MIGHT be PE!!!"), ocean of IVF, and, as a final note, cardiac stress test. This hospital has that "100% money back guarantee" and I'll make sure they do it this time.

    Thanks God that my current Powers That Are not only allow but even encourage us nurses thinking. At least sometimes.

  • Aug 23

    Quote from chare
    If your policies don't allow you to adjust the alarm parameters you need to contact the attending physician and have appropriate alarm limits ordered.
    I agree strongly - alarm fatigue is real.
    If a physician determines that a HR of 45 or what is "normal" for this patient, an order can be placed that indicates exactly that and to allow moving the alarm threshold. But it requires a MD order.
    An alarm that rings the whole time is not acceptable.

    In regard to my previous post : Let's say the nurse triggers the young athlete who has a HR of 40/min - the team comes and determines he is ok and it is acceptable and not a symptom of danger - they will give an order to change the alarm to let's say 39/min. But at least the physician looked at the patient! I have seen many cases in which the nurse thought the patient "is ok" despite abnormal parameters based on whatever feeling/knowledge and with a rapid response turns out the patient is actually not ok and there is a problem that needs to be corrected.
    The place I work at now is very different and I sometimes wonder why I have to mention that a resp rate above 30 is not normal and needs to be looked at or a constant alarm at the tele needs to be dealt with. The other day I saw a telemetry alarm going off indicated Vtach, which was a false alarm as the pat had wide complexes and the telemetry needed some re-learning and new lead placement. However, while I was sitting there charting several nurses came to silence the alarm without fixing that problem.

    Of course staffing is an issue - it is an issue everywhere in nursing now. And the work load combined with high acuity patients with complex problems can set up everybody to fail. Some of the floors are so busy with not sufficient amount of CNA so that nurses are left with "double" the work and less time to actually care for what is really relevant to the practice of the RN. In the meantime, since there are no telemetry techs anymore, alarms are ringing off the hook while the nurse is stuck with toiletting patients, bringing them water ans wash cloths and so on and forth. On one floor the manager timed the response from alarm going off to the nurse attending to the alarm. They made it clear that it is a priority to attend to a three star alarm right away not by just clicking at the telemetry station but to visibly check o the patient. Patient have died because alarm were silenced or thought to be "false" or not attended to (alarm fatigue - there was a lot about it in the news some years ago after some events became public).

  • Aug 23

    Quote from Here.I.Stand
    I agree completely with most of the other posters. A tool is one more thing that would need to be done on an already full to-do list... actually those big task lists are a big part of the problem. As others have brilliantly said, it puts the RN's eyes onto a computer/worksheet and takes them off the patients. It is no substitute for the RN laying eyes and hands on that patient. Plunking a RR onto an extra worksheet sheet ("extra" because it has already been documented on the VS flowsheet) is a task...noting the character of respirations, noting the patient's mental status, noting the "look" they have on their face is nursing assessment. Plunking a HR and BP on an extra worksheet is a task...noting at the color and temperature of their skin, and noting the patient's mental status is nursing assessment.

    A couple side stories: a while back I had a patient who was on trach dome all day, who had been guppy breathing but never *looked* like he was breathing comfortably. He was also minimally verbal so difficult to assess his mental status. I arrived for my 2nd shift with him. The previous day he would give me these big vacuous smiles whenever I talked to him...like he didn't necessarily understand me but was trying to be social. Well I go to assess him, and immediately feel something is off. His breathing doesn't look comfortable, but as the previous nurse said "it never did." But he had this expression on his face that reminded me of a dead fish, and he made no eye contact. The dr. came in and I said I really think he needs to go back on the vent. Something was off. MD ordered an ABG "to confirm," and his pCO2 came back in the mid 60s. It wasn't his RR or any other quantifiable number that told me something was off; it was his look and mental status.

    Another time while orienting in my former LTACH, we went to assess this one patient. Her HR and BP were a bit higher/lower respectively than her baseline but not terrible, but she was flushed and confused. She was becoming septic and we got her transferred into the ICU pretty quickly. Again, our clues were not worksheet-quantifiable numbers...turns out her WBCs were elevated, but labs weren't resulted for a couple more hours. So based on the info we had at the time, our clues were her mental status and the look/feel of her skin.

    I really don't see a substitute for nursing assessment; and proper RN : pt ratios, elimination of extraneous charting, elimination of customer service tasks, etc. that allow the time and focus to perform said assessments.
    I agree that it is the bedside assessment that most often reveals "something is wrong" even though objectively numbers may not be "that bad". Which is exactly were the Novice to Expert nurse model goes along.
    But I think even though a nurse may detect something is wrong, it often depends on the hospital culture and the MD how they react to it. In the hospital that requires to call a rapid response to ensure that those concerns are taken seriously, the attitude from MDs changed significantly. Now I work in a different hospital in which the nurses struggle at times with the MDs . My current place has a huge threshold to call a rapid response, which I do not agree with. The whole goal is to detect deteriorations earlier and prevent a code.
    In the hospital with the trigger program I took care of a young man in his 20s with complex neurological problems. His vitalsigns including oxygen looked ok, he was step down. But - when I did a quick follow up assessment some hours into my shift I found that his skin color had changed in a subtle way plus his breathing looked "odd" and I noticed just looking at him that the chest was not expanding as much but the abdominal area was shifting with breaths in a weird way. His lungsounds were diminished anyways and just more dim on one side. But when I looked at his neck I felt that there was a subtle deviation to the side. I called a rapid response asap as I was sure something was not ok, the patient was also not mentating as before.
    Low and behold the rapid response team comes and they are somewhat puzzled about me calling them - - but go to work for an in depth assessment. In the meantimes the xray techs come and do a bedside x ray. While the team is at the bedside, the respiratory status suddenly gets visibly worse and the pat requires a non re-breather mask. They decide to move him over from step down to ICU since something is going on. We were very quick getting him to the ICU. When I went over again to bring some of his clothes they told me to come and look at his x ray : His heart was pushed to the other side significantly due to a tension pneumothorax, which they relieved in the ICU asap. It was somewhat puzzling that this patient did not have more early symptoms but they thought because he was younger plus darker skin the signs were subtle. Point is - if I had not called a trigger event, the patient would have coded for sure probably soon after and changes of a good outcome not as good. Other members of the rapid response team told me later that at first they felt it was "nothing" when they entered the room but since the hospital has this policy they had to do an in depth assessment, during which the problems became significant.
    The program has not saved everybody but really decreased the amount of codes and bad outcomes. They also implemented other rules with it :
    If somebody got a rapid response within the first couple of hours after admission from the ER, critical care, post surgery it automatically translated in a thorough investigation as the patient should not be on a med/surg floor when not stable. That also cut back on pat coming up from the ER and ending on a non rebreather mask after an hour or so - now on a floor with less resources...

  • Aug 23

    Your post mentions tired, overworked nurses, yet your "solution" will do little other than to increase their documentation workload and worsen the problem. If you want better patient outcomes and risk minimization the way you get that is to staff adequately with appropriately trained and credentialed staff. This has been proven over and over again to be effective in minimizing negative outcomes. Hospitals will do anything else other than using the actual solution because that will cost them money. Sending nurses in circles designing contrived forms gives the illusion and veneer of trying to address the issue with positive steps all while doing the same things that have repeatedly failed elsewhere.

    The solution to the issues you describe is a simple and basic one that can be easily remedied if the powers that be were only willing to do so.

  • Aug 23

    I agree completely with most of the other posters. A tool is one more thing that would need to be done on an already full to-do list... actually those big task lists are a big part of the problem. As others have brilliantly said, it puts the RN's eyes onto a computer/worksheet and takes them off the patients. It is no substitute for the RN laying eyes and hands on that patient. Plunking a RR onto an extra worksheet sheet ("extra" because it has already been documented on the VS flowsheet) is a task...noting the character of respirations, noting the patient's mental status, noting the "look" they have on their face is nursing assessment. Plunking a HR and BP on an extra worksheet is a task...noting at the color and temperature of their skin, and noting the patient's mental status is nursing assessment.

    A couple side stories: a while back I had a patient who was on trach dome all day, who had been guppy breathing but never *looked* like he was breathing comfortably. He was also minimally verbal so difficult to assess his mental status. I arrived for my 2nd shift with him. The previous day he would give me these big vacuous smiles whenever I talked to him...like he didn't necessarily understand me but was trying to be social. Well I go to assess him, and immediately feel something is off. His breathing doesn't look comfortable, but as the previous nurse said "it never did." But he had this expression on his face that reminded me of a dead fish, and he made no eye contact. The dr. came in and I said I really think he needs to go back on the vent. Something was off. MD ordered an ABG "to confirm," and his pCO2 came back in the mid 60s. It wasn't his RR or any other quantifiable number that told me something was off; it was his look and mental status.

    Another time while orienting in my former LTACH, we went to assess this one patient. Her HR and BP were a bit higher/lower respectively than her baseline but not terrible, but she was flushed and confused. She was becoming septic and we got her transferred into the ICU pretty quickly. Again, our clues were not worksheet-quantifiable numbers...turns out her WBCs were elevated, but labs weren't resulted for a couple more hours. So based on the info we had at the time, our clues were her mental status and the look/feel of her skin.

    I really don't see a substitute for nursing assessment; and proper RN : pt ratios, elimination of extraneous charting, elimination of customer service tasks, etc. that allow the time and focus to perform said assessments.

  • Aug 23

    Quote from RNperdiem
    Is there an issue with inappropriate transfers or admissions to the floor where you work? Unfortunately, sometimes floor have to deal with "the stepdown needs a bed now, we are sending you Mr. Marginal Patient because he is the most stable", but he is really not ready for the transfer out.
    There might not be a quick fix on bed space, but there needs to be some authority to block admissions/transfers who really need a higher level of care and monitoring.
    This, too.

    The admission/transfer coordinators must be RN with at least good 5 years of bedside experience instead of someone marking checklists. And, BTW, float pool needs to include the most experienced, most clinically astute and most widely qualified RNs who would be comfortable with managing patienrs on "wrong" floor for a time. Float pool made from new grads and those who did not "fit" anywhere else is an invitation for disaster.

  • Aug 23

    Is there an issue with inappropriate transfers or admissions to the floor where you work? Unfortunately, sometimes floor have to deal with "the stepdown needs a bed now, we are sending you Mr. Marginal Patient because he is the most stable", but he is really not ready for the transfer out.
    There might not be a quick fix on bed space, but there needs to be some authority to block admissions/transfers who really need a higher level of care and monitoring.


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