Improving patient safety: Early recognition and a timely response to clinical deterioration

By Tammy Williams, RN, MSN, CPPS
Vizient PI Program Director

Early identification and response to clinical deterioration is key in avoiding preventable adverse patient outcomes. However, unrecognized clinical deterioration in non-critical care areas is common. A recent analysis of inpatient data submitted to Vizient's Patient Safety Organization (PSO) shows that unrecognized clinical deteriorations were among the most common events resulting in severe patient harm or death.

Hospitalized patients unknowingly decompensated in their room or during a transition in care and were found unresponsive, had unstable vital signs, or were in respiratory insufficiency or cardiopulmonary arrest, requiring initiation of a rapid response or code team. Warning signs of patient decline may have been present but were unwitnessed, unrecognized or not acted upon by the staff involved in their care. In some cases, vital signs were not taken or documented for extended periods, preventing calculation of an early warning score (EWS) or making that score unreliable and/or preventing awareness of clinical changes.

Studies show that many patients have documented signs of physiological deterioration prior to cardiac arrest, death and intensive care unit (ICU) admission. Hospitals commonly use rapid response systems to identify and respond to deteriorating patients outside of the ICU. Rapid response systems include criteria for clinical activation and the ability to rapidly deploy a team capable of providing critical care or transfer to a higher level of care. Early recognition is the most robust component of the rapid response systems in predicting success; however, despite patients meeting criteria, unit staff often fail to activate the team. Other challenges with activation criteria include failures in vital sign acquisition, documentation or accuracy and inaccuracies when manually calculating early warning scores.

Through conversations with Vizient provider experts, the following recommendations were developed for healthcare organizations to improve their timely response to clinical deterioration:

Develop a multidisciplinary oversight team: Assemble a team of clinicians (critical care and non-critical care nurses and physicians), rapid response members, performance improvement members and system/human factor engineers. Responsibilities of the team might include:

• Evaluate systems for real-time upload of vital signs in the electronic health record (EHR).
• Evaluate the efficacy of EWS systems, including more advanced machine learning models, and make recommendations.
• Map existing workflows and determine how the team will recognize and respond to clinical deterioration in a timely manner, including a readily visible display of warning scores. 
• Evaluate the possible unintended consequences of EWS systems and continuous surveillance, such as alarm and alert fatigue, and lack of capacity for unit staff to respond to alerts and evaluate the patient.
• Determine important process and outcome measures for the clinical deterioration program, including how the data will be collected, analyzed and shared for improvement.
• Develop and implement a plan for educating clinicians on the rapid response systems.
• Identify and address barriers to rapid response system activation in patients meeting activation criteria.

Select a good early warning system: A variety of models for activation of the rapid response systems have evolved overtime and include different clinical variables. Some are better than others. Conventional EWS systems outperform single vital signs thresholds, particularly when they are auto-calculated and linked to an auto-escalation protocol. Artificial intelligence, including machine learning and deep learning models, may work even better because they add a layer of prediction using interconnectedness and relationships of higher risk profiles to EWS systems. However, until they are more developed, having human filters review the patient data prior to an escalation remains a common strategy.

Determine vital signs based on the patient's condition/acuity: Assign responsibility for collection of vital signs based on the patient's needs. Real-time upload of vital signs to the EHR is ideal. Since failures in collection and documentation of vital signs is common, leaders should monitor and create accountability for timely collection and documentation. Surveillance monitoring is another option if challenges associated with excessive alarms, alerts and battery change requirements can be addressed.

Evaluate the end user interface: To ensure that clinicians' response to alerts is timely, the system should be designed so that all necessary clinical information such as EWS, vital signs, end-of-life cardiac resuscitation and life-sustaining treatment status is readily visible to the clinicians responsible for acting on the alert. Optimally, the EWS alert should direct the clinician on the necessary actions.

Define an effective workflow: Designating responsibility for evaluation of the algorithmic alert to a human reviewer prior to team activation may help prevent alert fatigue and address staff capacity issues. An automated process sends early warning system alerts to a dedicated person not caring for patients to validate actionable information and trigger the rapid response team to evaluate the patient. Parameters for initiation of the rapid response team activation are defined. If the person responsible for evaluating the alert is the primary nurse, there should be adequate staffing, so nurses have the capacity to respond to the alert, evaluate the patient and trigger the rapid response team. The rapid response team develops an appropriate differential diagnosis, gathers additional relevant data as needed and institutes effective evidence-based therapies, including transfer to a higher level of care to improve patient outcomes.

Ensure leader monitoring and oversight of the program: A health system management approach ensures the standard work is implemented as intended and achieves the desired results. Visual management boards can be used to track compliance with processes and progress.

To learn more, register for the Vizient PSO webinar, "Timely response to clinical deterioration," scheduled at 1-2 p.m. CT March 13 during Patient Safety Awareness Week. Vizient provider Dr. Bradford D. Winters, Ph.D., M.D., FCCM, a clinical expert and researcher from The John Hopkins School of Medicine, will discuss the challenges and evolving role of early detection systems, the potential for newer machine learning systems to improve patient safety and outcomes and the importance of having an effective clinical intervention response.