Opening the Lines of Communication

Early returns of study show better communication can decrease ICU admissions

The importance of free-flowing, honest communication in healthcare has never been underestimated. Over the years, technological advances have ensured that doctors, nurses, patients, families, and other interested parties are accessible to one another at all times, with the promise of better outcomes as a result.

Now, hospitals are starting to quantify those improvements. The results of a recent pilot study shows the results of the development and implementation of a new communication bundle at a hospital in New Hampshire.

The American Journal of Critical Care (AJCC) published “Early Warning Score Communication Bundle: A Pilot Study” earlier this month. It follows the saga at Southern New Hampshire Medical Center, a 189-bed, Magnet-recognized facility in Nashua, NH.

The study aimed to address the problem of medical-surgical patients being transferred unexpectedly to the intensive care unit (ICU). They accomplished this by including a seven-item early warning score (EWS) method into their electronic medical record (EMR) system. Patients in four separate med-surg units plus the ICU were included.

Possible scores ranged from 0–21 on the scale, with scores of 4 or higher triggering an automated warning in the form of a red exclamation point next to the patient’s name of the record, plus a warning sent to the nurse or unit leader.

“Unplanned admissions of patients to intensive care units from medical-surgical units often result from failure to recognize clinical deterioration,” read the study. “The early warning score is a clinical decision support tool for nurse surveillance but must be communicated to nurses and implemented appropriately. A communication process including collaboration with experienced intensive care unit nurses may reduce unplanned transfers.”

“The early-warning score helps identify patients with clinical signs of deterioration, but that information must be quickly communicated to a nurse with an appreciation for the urgency of the situation and the knowledge to take action,” said primary investigator Cheryl Gagne, RN, DNP, CNEA, chief nursing officer at the hospital. “Our communication bundle may have led to earlier and more effective interventions by medical-surgical nurses, facilitated by collaboration with experienced critical care nurses.”

Early warning scores gained popularity back in the 1990s as a means of assessing and warning of patient deterioration. EWS are determined by a nurse’s assessment of physiological factors including blood pressure, heart rate, and body temperature. Specific scores prompt immediate attention as needed.

For this study, a seven-item, modified EWS system was utilized, including the following elements:

  • Central nervous system
  • Respiratory rate (breaths per minute)
  • Heart rate (beats per minute)
  • Systolic blood pressure (mm Hg)
  • Body temperature
  • Oxygen saturation with therapy, %
  • Urine output in >/= 2h, mL/h

Each item is assigned a score from 0–3, with higher scores signaling greater deterioration. As mentioned, any score 4 or higher triggers the automatic alert.

Before implementation of this system, the number of calls to a rapid response team was 6.47 per 1,000 patient days, with medical-surgical transfers accounting for over 21 percent of ICU admissions. Moreover, almost 45 percent of medical-surgical patients who received a rapid response team call were ultimately transferred to the ICU.

Analysis of 18 months, or 6 quarters worth of data post implementation yielded the following information:

  • Rapid response team calls increased from 6.47 to 8.29 per 1,000 patient days (a finding the researchers deemed insignificant)
  • Calls for patients with an EWS of 4 or above declined
  • In five of the 6 quarters, medical-surgical transfers to the ICU declined

“ICU admissions of patients who had received a rapid response team (RRT) call have declined significantly,” wrote the researchers, “as did ICU admissions of patients with an EWS greater than 4. EWS response time decreased significantly, indicating a successful implementation of the communication bundle.”

The increase in RRT calls resembled results of similar studies; however, an interesting finding from the New Hampshire-based study was that the increase in RRT calls came from those patients with lower EWS scores, and in fact fewer patients who received an RRT call exhibited elevated EWS scores. Overall, ICU admissions declined.

“The EWS is a clinical measurement tool that complements nursing judgment,” wrote the researchers. “Electronic surveillance together with experienced ICU nurse collaboration has the potential to improve care, preserve health care dollars, and save lives. An electronically embedded EWS together with a communication bundle reduced ICU admissions from medical-surgical units and decreased patient morbidity. Obtaining the perspective of nurses implementing the EWS communication bundle is warranted.”

SOURCES: American Association of Critical-Care Nurses, AJCC

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