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?

[BeenThere2012, ASN, RN]

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.

[Mommavik, ADN]

I totally agree! I've seen this again and again; trying to make rounds and assess my patients before doing my 1st med rounds, if my 3rd patient needs to talk to me to express her worry about what the doctor said about her diagnosis and to cry on my shoulder:that IS part of being a nurse, but who among us in these days of having 8 to 10 patients to assess, give meds,do treatments, monitor test results, talk with doctors, etc has the time to do this and still keep the other things on our schedule on track? So sad. ..

[Caffeine_IV]

I like the MEWS and that is what we have at our hospital. Of course nothing is error proof but it does help give insight to a.patient that may need closer monitoring

Some of the other subtle assessment changes are things that many nurses only learn through experience. And once you see it, it stays with you.

Time permitting when we have a patient go bad, we discuss among ourselves what happened...what we may have missed.

There is a difference in being too busy to round and assess and not knowing what signs to be alert for.

[Kooky Korky, BSN, RN]

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']

Not being rude, but you are on the Council, not the Counsel. Just sayin'.

Sounds like you are sold on this new form/task.

[ivyleaf]

10 minutes for 6 pts= a whole hour spent on extra documentation

[Here.I.Stand, BSN, RN]

It is designed to take about 10 minutes or less to fill out once the nurse gets the hang of it.

10 minutes per patient? On a typical med-surg floor, that's roughly an hour of extra work.

[Here.I.Stand, BSN, RN]

10 minutes for 6 pts= a whole hour spent on extra documentation

And you beat me to that point!

[nutella, MSN, RN]

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.

The facility I mentioned earlier with the mandatory trigger program also included "family requested rapid response" and it was successful. People first thought that family would use that all the time but that was not the case. The times that family requested a rapid response were very legit and often pointed to problems that were not realized because the staff did not know the patient or the staff was inexperienced and did not realize it was a problem.

I agree that skill mix and inexperienced staff is a huge factor.

And I also realize that when you work at a hospital that does not hold their physicians very accountable even experienced nurses won't change a thing...

[blondy2061h, MSN, RN]

We had signs posted in all patient rooms with the rapid response numbers for years for family members to call. The signs have since disappeared, but I don't remember a family member ever calling a rapid. I guess if they acknowledged seeing that sign they'd have to acknowledge seeing the "max of two visitors at a time" one right next to it.

[TrishaRNSCCU]

I love your idea! I work ICU with PCU pts as well. It will be 1:3 at times and believe me one ICU pt with 2 PCU is a bear to handle. We do not have a CNA on the floor and its horrible. True ICU is 1:1 or 1:2 without CNA. I work for a "for-profit" hospital and believe that I shouldn't risk my license and my patient's safety in order to make the corporation money. The pt on vasopressors, pain, sedation, etc. Is not the only pt at risk. I had 3 pts the other day and the cardiac obs pt is the one that I knew, from experience in ICU, that he would be the one that I had to keep my eye on. Unfortunately, I was correct. He ended up coding. I was in his room, by his side. Called a code for vtach, sustained vtach. 45 minutes later we finally had him stabilized enough for cardiologist to review his case and perform surgery. Oh but we face you an extra pt because he's just observation they said. Sure! I do my job to save people's lives or assist them at the end. Not to make money for a corporation while every nurse I know in Idaho is struggling to pay our student loans, because we have some of the lowest wages in the nation. CNA on floor plus better nurse to pt ratio should be a national standard. After all that, there was still baths, meds, room trash, linens to change, and everything else that needs to be done, on all 3 of my patients by myself. I work night shift. They just know that we will get it done.

[Lev, MSN, RN, NP]

Like I mentioned before this would replace some other documentation which is deemed "less useful."