Efforts to improve outcomes of patients who deteriorate outside the intensive care unit have included the use of rapid response teams (RRTs) as well as manual and automated prognostic scores. Although automated early warning systems (EWSs) are starting to enter clinical practice, there are few reports describing implementation and the processes required to integrate early warning approaches into hospitalists’ workflows. We describe the implementation process at 2 community hospitals that deployed an EWS. We employed the Institute for Healthcare Improvement’s iterative Plan-Do-Study-Act approach. Our basic workflow, which relies on having an RRT nurse and the EWS’s 12-hour outcome time frame, has been accepted by clinicians and has not been associated with patient complaints. Whereas our main objective was to develop a set of workflows for integrating the electronic medical record EWS into clinical practice, we also uncovered issues that must be addressed prior to disseminating this intervention to other hospitals. One problematic area is that of documentation following an alert. Other areas that must be addressed prior to disseminating the intervention include the need for educating clinicians on the rationale for deploying the EWS, careful consideration of interdepartment service agreements, clear definition of clinician responsibilities, pragmatic documentation standards, and how to communicate with patients. In addition to the deployment of the EWS to other hospitals, a future direction for our teams will be to characterize process-outcomes relationships in the clinical response itself.
Background: Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals. Challenge: How can one deploy an RRS using an automated EWS at scale? Solution: EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards. Results: The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.
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