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Communication bundle helps med-surg patients avoid ICU
Up to 40% of ICU admissions might be avoidable with bundle
By
Lisette Hilton
Cheryl Gagne, RN
Sue Fetzer, RN
When nurses at a New Hampshire community hospital designed a communication bundle by combining an electronic early warning score system and nurses’ judgment, it made a significant impact on patient outcomes. The result was a reduction in ICU admissions from med-surg units, according to Cheryl Gagne, DNP, RN, CNEA, CNO at Southern New Hampshire Medical Center.
Gagne, along with Susan Fetzer, PhD, RN, a nurse researcher in patient care services at the Nashua, N.H.-based hospital, reported
findings of their pilot study
on the early warning score communication bundle May 2018 in the American Journal of Critical Care. Recognizing clinical deterioration early can prevent unplanned patient admissions to ICUs from med-surg units. In fact, the authors report up to 40% of ICU admissions might be avoidable. “Early recognition and prevention of deterioration has many health benefits for patients,” Gagne said. “Failure to recognize early signs of clinical deterioration can lead to increased likelihood of failure to rescue events that are accompanied by unintended consequences and injury for patients.” Care bundles, according to the
Institute for Healthcare Improvement
, are evidence-based interventions bundled together to improve patient outcomes. Gagne and Fetzer applied the concept to develop a communication bundle aimed at making more timely assessments of and interventions for med/surg patients whose conditions are deteriorating. In their pilot study, they studied the bundle’s impact on ICU patient admissions, patient morbidity and rapid response team calls from med-surg units at Southern New Hampshire Medical Center, a 189-bed Magnet-designated community hospital.
How the communication bundle works
The electronic medical record embedded early warning score flags for med-surg patients with early clinical signs of deterioration. The scoring is based on seven items, including heart rate and urine output. With possible scores ranging from 0 to 21, a score greater than 4 alerts nurses and others by displaying a red exclamation point alongside the patient’s name in the hospital EMR. This sends an electronic page with necessary information to an experienced ICU nurse — one assigned to respond to rapid response team calls. The nurse reviews the early warning score and calls the patient’s med-surg nurse to discuss the patient’s situation and formulate a plan.
ICU admissions of patients with early-warning scores greater than 4 declined from 2.04 to 1.77 per 1,000 patient days. This suggests staff identified patients with deteriorating conditions earlier with the intervention.
Study comparison finds bundle effective
The researchers looked at data three months prior to the bundle’s implementation and compared that to 18 months after implementation. They found patient ICU admissions post-rapid response team calls decreased. ICU admissions of patients with early-warning scores greater than 4 declined from 2.04 to 1.77 per 1,000 patient days. This suggests staff identified patients with deteriorating conditions earlier with the intervention. In other findings, adding the communication bundle resulted in a significant decrease in response time to the early warning score alert on the EMR. Rapid response team calls for patients with early warning scores greater than 4 decreased, but overall rapid response team calls went up insignificantly. The authors suggest that could have been because the bundle prompted intervention before a patient’s score increased. “The decline in ICU patients with [early warning scores] greater than 4 admitted to the ICU reflects a decrease in transfer morbidity,” researchers wrote in the study.
Nursing-centric tool improves total patient care
The combination of electronic surveillance and experienced ICU nurse collaboration has the potential to improve care, save healthcare dollars and save lives, according to the authors. “EMR-based rules engines are effective tools for timely evaluation of patients exhibiting signs of clinical deterioration,” Gagne said in an email. “Ongoing monitoring of patient’s health data using electronic surveillance can reduce the severity of crisis calls — meaning the med-surg nurse may be able to pre-empt a rapid response team call. Experienced ICU nurses can function effectively in the role of clinical consultants to med-surg nurses.” This isn’t the first early warning score tool, but it is different, according to Gagne. More than 30 early warning score tools existed when this project began. Physicians had created many of the existing tools, which only incorporated patient information important to physicians’ practices. “This is perhaps one of the challenges incurred when attempting to validate the tool,” Gagne said. “This particular tool was chosen because of its incorporation of data that is typically collected by nursing staff. While customization is always possible, I do believe the tool described in this article suffices.” An important takeaway from this study is the ability of med-surg and ICU nurses to work together in clinical decision making, Fetzer said. Fetzer said they frequently hear of turf wars, but in this situation teamwork benefited everyone. “The finding that critical rapid response team [calls] decreased, indicated that med/surg nurses were being proactive,” Fetzer said. “One would hypothesize that this suggests they felt supported in their decision making. As a Magnet facility for over 12 years, these findings support nurse autonomy that promotes nurse satisfaction.” Further research looking at nurses’ perspectives when implementing the early warning score communication bundle is warranted, according to the study.
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EDITOR'S NOTE:
Lisette Hilton is a freelance writer.
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