Subtle deterioration on the floor

Been there,done that, ASN, RN · Aug 22, 2016

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']
That would be another form to fill out at the end of my shift. Taking my time and attention from face to face patient interaction... where I COULD notice a change.
Overworked nurses need mandatory education to teach them to use their assessment skills, and not focus on documentation.
In other words.. look at the patient..instead of your computer screen.

nutella, MSN, RN · Aug 22, 2016

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.

Once the initial trigger event lead to the physician determining that there is no danger , for example HR 45 /min without symptoms in athletes, it would be just monitored and not called another trigger unless new symptoms occur. But this is exactly why calling a rapid response is good - it takes the guess work out. As nurses we might think that it is ok but perhaps it is not. This is exactly the kind of situation that could result in nurses not pressing for the MD to evaluate the patient. It also forces the physician to take action as there is a documentation. And they are not free to just say "don't worry -I will come later" or such. The point is that somebody else reviews the case with a fresh pair of eyes. I had cases were the nursing supervisor and MD decided that a HR above something could be tolerated but in many cases calling a trigger event actually did change something.

nutella, MSN, RN · Aug 22, 2016

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...

nutella, MSN, RN · Aug 22, 2016

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).

blondy2061h, MSN, RN · Aug 22, 2016

Once the initial trigger event lead to the physician determining that there is no danger , for example HR 45 /min without symptoms in athletes, it would be just monitored and not called another trigger unless new symptoms occur. But this is exactly why calling a rapid response is good - it takes the guess work out. As nurses we might think that it is ok but perhaps it is not. This is exactly the kind of situation that could result in nurses not pressing for the MD to evaluate the patient. It also forces the physician to take action as there is a documentation. And they are not free to just say "don't worry -I will come later" or such. The point is that somebody else reviews the case with a fresh pair of eyes. I had cases were the nursing supervisor and MD decided that a HR above something could be tolerated but in many cases calling a trigger event actually did change something.

So the rapid response triggers are the same for everyone? I hope you have a dedicated rapid response team with a policy like this.

Lev, MSN, RN, NP · Aug 22, 2016

What a great discussion! The things everyone mentioned is what I feared, that nurses are just too busy to fill out another checklist and we just need to hire more staff. Unfortunately, hiring more staff is less likely to happen than more things for us to document. Some people have mentioned that the nurses assessment is more important than vital signs and even the vital signs alone don't mean something is wrong. For example, with baseline bradycardia or hypotension. The tool incorporates that. I made up the tool sort of like an algorithm. It is pretty complex but could take 10 minutes to fill out once someone is used to filling it out. However, some other form of "petty" documentation would have to removed before another form of documentation is added. I will post the tool when I am not typing on the phone.

whichone'spink, BSN, RN · Aug 22, 2016

What a great discussion! The things everyone mentioned is what I feared that nurses are just too busy to fill out another checklist and we just need to hire more staff. Unfortunately, hiring more staff is less likely to happen than more things for us to document. Some people have mentioned that the nurses assessment is more important than vital signs and even the vital signs alone don't mean something is wrong. For example, with baseline bradycardia or hypotension. The tool incorporates that. I made up the tool sort of like an algorithm. It is pretty complex but could take 10 minutes to fill out once someone is used to filling it out. However, some other form of "petty" documentation would have to removed before another form of documentation is added. I will post the tool when I am not typing on the phone.[/quote']
But that's not how it's going to happen, and you know it. No documentation will be removed, and your tool will just be another burden on floor nurses.
This is why I've become disillusioned with informatics. Informatics is supposed to benefit clinicians by make technology more user friendly, for the benefit of clinicians and ultimately, patients. Informatics has turned nurses, and providers, into no more than data collectors.

AutumnApple · Aug 22, 2016

Ditto to those who pointed out: Don't just add another form, another task to do, then expect it to solve anything. That's the thought pattern/process of detached administration and it hasn't helped up to now so..........don't walk into the same wall expecting different results.

My experience has shown me that the solution to your problem lies in the routines and details of the care process already in place.

What I mean by that is, to help the problem, you don't necessarily have to create anything epic and new. Chances are, better detection of at risk patients will probably happen with better implementation of the tools already at hand.

You already mentioned one problem I dealt with at my first job: Decreased urine output. My unit would be ready to discharge someone only to have the patient say to the doctor "Oh, by the way, I've not pee'd in a while.............". This would result in the doctor being upset that the nurses weren't aware and an extended stay for the patient. Another problem that came up frequently was, the patient would not void for an entire shift (or void very little) and it would not be handled by the nurse of said shift. It'd be reported (most of the time) but not addressed.

This unit had a high patient ratio for nurses, but did have a good team of CNA's working on it at the same time. Details that, once known, were obviously things that needed attention.........often went unnoticed or poorly handled.

I was on the committee that was to address it. Everyone at the monthly meeting was giving epic, grand solutions to the problem. Buy this new equipment or change the disciplinary policies for not addressing the problem or create this/that form to fill out.

I was of the opinion that there had to be a simpler, more practical way to improve the situation. It seemed to me my peers were not seeing the forest through the tree.

I was right. You see, here is what I saw taking place on my unit (as I mentioned, the CNA's were well trained and performed their role well):

New shift reports in and take over patient care. As the shift moves along, the nurse gets distracted with patient requests, med passes and all sorts of other things. All the while, the CNA's were doing their tasks. Patients would tell them they voided (or didn't), I/O's were kept on a paper to be totaled at the end of the shift and caths were emptied as needed and at the end of the shift.

So, you have a CNA keeping I/O totals then recording the final results at the end of their shift.

That was our problem. The nurse didn't know about the issue until the end of the shift when the CNA's put the totals and data into the computer.

In the end, we didn't order any new equipment or up the disciplinary policies. It was clear to me that while it is nice to have urinary caths emptied for us and the hats in the toilets changed by the aids, this put the CNA in a position that required them to make a judgement call. In short, they were having to ASSESS whether something was worth reporting immediately or not. That is outside their scope of practice.

So, doing those specific tasks became the nurse's. We also educated the CNA's on reporting I/O data to the nurses, whether it be "an emergency" or not.

Duties were juggled and rearranged to make up for the extra responsibilities put on the nurses. In fact, our handling of this issue (and a few other factors) lead to the hospital admin. agreeing to hire a New Admit nurse. So, in the end, the nurses weren't overburdened, it's just that their focus and responsibilities had to be shifted a bit.

KatieMI, BSN, MSN, RN · Aug 22, 2016

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.

HouTx, BSN, MSN, EdD · Aug 22, 2016

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.

blondy2061h, MSN, RN · Aug 22, 2016

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.

compassionresearcher · Aug 23, 2016

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!