Incorporating an Early Detection System Into Routine Clinical Practice in Two Community Hospitals

Abstract

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.

Early detection, prevention, and mitigation of critical illness outside intensive care settings

“…Escobar et al 24 describe the quantitative as well as the electronic architecture of an early warning system (EWS) pilot at 2 hospitals that are part of an integrated healthcare delivery system. Dummett et al 25 then show how a clinical rescue component was developed to take advantage of the EWS, whereas Granich et al 26 describe the complementary component (integration of supportive care and ensuring that patient preferences are respected). The paper by Liu et al 27 concludes by placing all of this work in a much broader context, that of the learning healthcare system.…”

Early detection of critical illness outside the intensive care unit: Clarifying treatment plans and honoring goals of care using a supportive care team

“…Second, having social workers available 24 hours a day/7 days a week as backup for busy hospitalists, is essential. Finally, as is described by Dummett et al, including reminders regarding patient preferences in the documentation process (by embedding it in an automated note template) is also very important.…”

What Do We Do After the Pilot Is Done? Implementation of a Hospital Early Warning System at Scale

“…In a recently described pilot, [25][26][27][28][29] we implemented an RRS for general medical/surgical ward patients at 2 KPNC hospitals. The pilot sites, which went live in 2013 and 2014, had 120 and 333 beds and 7,000 and 14,000 annual discharges, respectively.…”

“…Initial experience with deployment led our team to modify the readiness checklist we reported previously. 27 We developed specific temporal requirements ( Figure 4 ) that are linked to the checklist shown in Table 2 (they are extensively detailed in a playbook included in the Appendix).…”