Subtle deterioration on the floor

[Lev, MSN, RN, NP]

I am on my hospital's nurse practice counsel and recently the discussion turned to nurses failing to recognize declining patients before it is too late. Before I was an ER nurse, I was a floor nurse. When you have 5-7+ patient to juggle at a given time you can barely focus your attention on one patient for minutes at a time in the midst of endless med passes and documentation. What is your hospital doing to improve this issue? I am aware that the EPIC charting system has an Early Warning Score (EWS) built in based off the vital signs. However, even a slight change in mental status (including anxiety) and decreased urine output are two possible signs of deterioration other than changes in vital signs. I am trying to create a generic electronic tool that nurses, particularly med-surg and telemetry nurses with high patient loads, would fill out 6 hours into the shift which will help them determine when to be alarmed and notify the physician to intervene. What do you think about this issue and my idea?

[oncivrn]

Theoretically a nice idea but you have to make sure it's not just something that has to be completed and takes the nurse away from the bedside

Imo, too much time filling out meaningless care plans and over documentation takes nurses away from their patients and puts patients at risk

[dream'n, BSN, RN]

With all due respect, I think focusing on making another tool for nurse's to complete is contrary to the rest of your post about overworked, overwhelmed nurses. Nurse's are too busy to notice patient changes because they are overwhelmed, so let's add more checklists/documentation?? Um, no. How about we add more nurses??

[Sour Lemon]

I agree with the others. Adding more "things" to do won't help.

[Anna Flaxis, BSN, RN]

I think that the failure to recognize early signs of deterioration is a worthwhile issue to explore, but before you implement process improvement measures, it is important to find out what is at the root cause. Many different variables can factor in. What is the staffing matrix for the unit? What is the skill mix (RNs, LPNs, CNAs, Techs, ancillary staff, etc.)? What about experience; how many veteran nurses and new grads are there? How many RNs hold certification in their area of practice? What about education; does the facility provide inservices on a regular basis or offer classes either on the company intranet or in a live format? What about relations between nursing staff and physicians; what is the typical communication process and what, if any, barriers or glitches occur? At what percentage are core measures being met? And lastly, you should compare the rates of sentinel events/poor outcomes/code blues etc. at your facility with that of a few other facilities similar to yours. Is this really a problem, or are you doing better than you think?

[AJJKRN]

I personally think it is more of a retention and patient ratio numbers game that a checklist just won't solve. The EWS only truly works with frequent VS and I&Os in itself and decreased urine output is a later sign, as you know, but easy to miss without a foley or up to date documentation.

The last time I did CPR (not but a few months ago mind you) I was on a floor at shift change and happened to be the most experienced nurse there between both shifts with everyone else having a year or less experience. I work nightshift so that means all of day shift, including their charge, was that experienced.

Dude straight up just flat lined, no pulse, but by the grace of powers beyond me, I had a pulse back and a fairly stable patient by the time the code team got there because the code was called later than it should because no one except me really new how to call it. Instead of just calling security to overhead page they had been pushing a button on the wall that apparently wasn't working yet as it was a new build floor!

I hope you do find more helpful comments that don't take quite as long to implement for safety!

[cleback]

That's the holy grail of nursing. Not sure if that's realistically achievable.

[nutella, MSN, RN]

I am on my hospital's nurse practice counsel and recently the discussion turned to nurses failing to recognize declining patients before it is too late. Before I was an ER nurse I was a floor nurse. When you have 5-7+ patient to juggle at a given time you can barely focus your attention on one patient for minutes at a time in the midst of endless med passes and documentation. What is your hospital doing to improve this issue? I am aware that the EPIC charting system has an Early Warning Score (EWS) built in based off the vital signs. However, even a slight change in mental status (including anxiety) and decreased urine output are two possible signs of deterioration other than changes in vital signs. I am trying to create a generic electronic tool that nurses, particularly med-surg and telemetry nurses with high patient loads, would fill out 6 hours into the shift which will help them determine when to be alarmed and notify the physician to intervene. What do you think about this issue and my idea?[/quote']

While I like the idea of a tool it will most likely not change anything in practice. Because it is not timely enough. If something is not ok, it may not make a difference 6 hours later or such.

One of the hospitals I worked at implemented a mandatory rapid response program that actually did change patient outcomes.

The way it works is that if a patient VS are outside of the established parameters, for example HR above 120/min or less than 50, O2 sat less than 90%, RR above 30 per minute or less than ... any change in mental status. And the important element is that it is mandatory to call a rapid response for that - no exemption. So physicians do not give nurses a hard time as it is policy and the rapid response team provides the other set of eyes that you do not have as a busy nurse.

That policy saved lives. Some nurses did not want to call a trigger or the MD tried to convince them to "lay low" but leadership was very adamant and made sure they know that they will be written up if they fail to call a trigger.

[blondy2061h, MSN, RN]

Adding another check list is anther thing that takes eyes off of patients. Eyes on patients is what you need.

One thing you can do is make sure nurses are well inserviced on sepsis warning signs and encouraged to call a rapid response whenever they're concerned.

Our EMR does have a sepsis alert system built in that considers vitals, labs, urine output, and mental status and creates an alert to providers if two criteria are met. It's helpful, but our problem is that one of the criteria is HR>115 and another is SBP

[blondy2061h, MSN, RN]

While I like the idea of a tool it will most likely not change anything in practice. Because it is not timely enough. If something is not ok, it may not make a difference 6 hours later or such.

One of the hospitals I worked at implemented a mandatory rapid response program that actually did change patient outcomes.

The way it works is that if a patient VS are outside of the established parameters, for example HR above 120/min or less than 50, O2 sat less than 90%, RR above 30 per minute or less than ... any change in mental status. And the important element is that it is mandatory to call a rapid response for that - no exemption. So physicians do not give nurses a hard time as it is policy and the rapid response team provides the other set of eyes that you do not have as a busy nurse.

That policy saved lives. Some nurses did not want to call a trigger or the MD tried to convince them to "lay low" but leadership was very adamant and made sure they know that they will be written up if they fail to call a trigger.

How were athletes with resting HR's of 40 and COPDers who haven't had an O2 sat above 87% since the Bush Junior administration handled? My asthma admissions when I'm on steroids and theophylline and ATC albuterol my HR stays above 120 the entire admission.

[Everline]

Hire more nurses.

[KatieMI, BSN, MSN, RN]

The problem is, signs and symptoms of deterioration are many, individual and can be difficult to detect. One cannot reliably detect decrease in urine output over, say, 4 hours unless patient has Foley. Med/surg floors may not have capacity to put every single patient on tele monitor and techs are not typically follow each trace close enough to detect QRS prolongation, for example.

To see, notice, analyze and report signs of changing conditions nurses have to be pulled off screens, papers, spreadsheets, checklists, etc., and back to patients' rooms. They also needed to be relieved from "customer service" scutwork as much as possible, and get more involved in bedside care. Where I work, we have excellent CNAs but I allow them to take my patients' vitals only if I am out of floor because I assess while doing it. I also try not to delegate toileting whenever possible, because it adds a lot to my asessment. And my CNAs know to get me in a second they noticed something - however strange.

Hire more nurses to let them do clinical nursing, and more CNAs to bring water and fluff pillows.