Subtle deterioration on the floor

[Lev]

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?

[RNperdiem, RN]

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.

[KatieMI, BSN, MSN, RN]

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.

[Here.I.Stand, BSN, RN]

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.

[DeeAngel]

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.

[chare]

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?

Nothing need be done, if these are the patient's baseline values.

My asthma admissions when I'm on steroids and theophylline and ATC albuterol my HR stays above 120 the entire admission.

Again, these are baseline values, and appropriate for your clinical situation.

[KatieMI, BSN, MSN, RN]

Again, these are baseline values, and appropriate for your clinical situation.

Please kindly let it be known to that monitor which was ringing like crazy for hours for patient's normal HR of 35 to 40. To just go there and re-program the darn thing was against some schmolicy. Thanks God some family complained and the show stopped.

[chare]

Please kindly let it be known to that monitor which was ringing like crazy for hours for patient's normal HR of 35 to 40. To just go there and re-program the darn thing was against some schmolicy. Thanks God some family complained and the show stopped.

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.

[blondy2061h, MSN, RN]

Nothing need be done, if these are the patient's baseline values.

Again, these are baseline values, and appropriate for your clinical situation.

Did you read the post I quoted? The person said the facility she worked at wrote people up if they didn't call a rapid response if vitals were above or below parameters. She didn't mention any exception for patients' baselines, hence my question.

[chare]

Did you read the post I quoted? The person said the facility she worked at wrote people up if they didn't call a rapid response if vitals were above or below parameters. She didn't mention any exception for patients' baselines, hence my question.

Yes, I did. The post in question stated that a rapid response is to be called when vital signs are outside of established parameters (emphasis added):

[…]

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…

[…]

It is incumbent on the bedside nurse to contact the attending provider and ensure that appropriate alarm limits are identified for patients based upon their baseline values, and not an arbitrary set of numbers.

[KatieMI, BSN, MSN, RN]

Yes, I did. The post in question stated that a rapid response is to be called when vital signs are outside of established parameters (emphasis added):

It is incumbent on the bedside nurse to contact the attending provider and ensure that appropriate alarm limits are identified for patients based upon their baseline values, and not an arbitrary set of numbers.

... and also asking for an order is one thing, but overcoming a schmolicy which says that monitors' settings cannot be changed is totally another one.

I had to sign AMA from ER less than a month ago because nurses there physically couldn't live their lives with one patient' BP below 100/70 (baseline 90/60 when active, the time was 3 A.M. and I had two doses of Benadryl IV at that time, so it was in mid-80th for systolic, asymptomatic otherwise). One of them practically threw a tantrum, yelling over the phone to her supervisor that the poor doc "refused to theat my patient who is in shock according to criteria". No explanations were enough for them, because they had policies and criteria. I had to run, sleepy as a bat.

[chare]

... and also asking for an order is one thing, but overcoming a schmolicy which says that monitors' settings cannot be changed is totally another one.

If your facility's policy truly says that you can't adjust alarm limits to ranges more appropriate for the patient's condition, you should ask whomever is responsible for that policy if they have heard of the Joint Commission Patient Safety Goal on Alarm Management (PDF).

Healthcare Business and Technology also published New for 2016: Joint Commission updates alarm guidelines, which briefly describes Joint Commission expectations in implementing this safety goal.

I had to sign AMA from ER less than a month ago because nurses there physically couldn't live their lives with one patient' BP below 100/70 (baseline 90/60 when active, the time was 3 A.M. and I had two doses of Benadryl IV at that time, so it was in mid-80th for systolic, asymptomatic otherwise). One of them practically threw a tantrum, yelling over the phone to her supervisor that the poor doc "refused to theat my patient who is in shock according to criteria". No explanations were enough for them, because they had policies and criteria. I had to run, sleepy as a bat.

This is actually scary. It also provides further support for not having a standard set of alarm limits that you apply to all patients.

[Leonardo Del Toro, RN]

When I chart and try to follow the dozens of processes in place to either "achieve better results"; "improve safety"; "better patient satisfaction" and the list go on and on I'm perplexed with one question: who in the world will carry out these orders? How are you going to load a 5th thing on the back of a nurse who is already doing 3 things too much. In essence, how are you going to place 5 cars in one car garage? I am so tired of watching administration and other office people spend all their day designing schemes after schemes and no spend one minute thinking of who...who will actually have time to implement any thing at all...hire more nurses, well that is out of question sir.