What Works -- Part 6 -- Triggers

If you are a patient in an academic medical center, who is watching over you in the middle of the night? Chances are it is a young nurse or intern, among the least experienced people in the hospital. Do these folks have the judgment and experience to respond to potential patient instability?

So imagine, on a regular late night visit to the room, a nurse notices that a patient has developed a fast respiratory rate, a drop in blood pressure, a drop in blood oxygen saturation, or a drop in urine production. S/he needs to make a decision about whether to call the intern. When the doctor returns the call, s/he needs to decide whether or not to actually come to see the patient -- or to just make treatment recommendations over the phone. Then, the intern needs to decide whether or not to wake up a more senior resident or the attending doctor in charge of the patient -- or to make the decisions around changing the plan of care autonomously.

The next morning, after rounds, the attending or another senior physician arrives and decides that there is a need to change the patient's treatment regime or even move the patient to the ICU because of a severely deteriorated condition. Hours of proper attention have been delayed, and the treatment plan now has to make up for lost time.

Or worse, before the attending arrives, the patient suffers cardiac arrest and a "code blue" is called to resuscitate the person.

Extreme example, maybe. Exaggeration of the usual mode of care, no.

When a patient on a medical or surgical unit becomes unstable, early intervention can be very important. Knowing this, the Institute for Healthcare Improvement has recommended that hospitals deploy a response team at the first signs of a patient's decline. But, how do you make sure this happens in the middle of the night? Standardizing a response makes a lot of sense when you think about the complex communication systems that exist in most hospitals.

In 2004, a series of events led us to recognize the need to change. First, a journal entitled Critical Care Medicine published an article in April on rapid response teams that caught the attention of our ICU doctors. Next, we had two very serious adverse events in which well-meaning, very involved junior providers did not recognize the tempo of patients' deteriorating condition. Our folks analyzed those cases and concluded that the care patterns for "acutely decompensating inpatients were complicated, sometimes disorganized, and had multiple single-point failure modes." Among other things, we conducted a survey of our house staff (i.e, the interns and residents) and found that they would contact attending physicians for many acute patient events only about 25 percent of the time. This suggested an area for major improvement.

(But first, an aside. Why wouldn't an intern or resident call the attending physician? Part of the mentality of medical training is an overstated belief that you don't really learn unless you do it yourself. Young doctors often believe that it will be viewed as a sign of weakness to call for help. Their senior residents reinforce that belief, based on their own training.

Another factor is the outright fear of calling an attending physician at 2:30 in the morning and getting the following response: "You woke me up for THAT?! What did they teach you in medical school anyway???")

Here is how things are today at BIDMC. The nurse notices that the patient has developed a certain condition, based on a standardized set of criteria (Triggers). The nurse is required to call the doctor, the senior nurse in charge and the respiratory therapist -- and they all come to see the patient. They collaborate on a plan of care for the patient going forward. Regardless of the time of day or night, the intern/resident then calls the attending doctor in charge of the patient to let him/her know that the patient has "triggered".

The standard set of Triggers we use are based on changes in heart rate, blood pressure, oxygen saturation, urine output, an acute change in the patient's conscious state, or marked nursing concern. Wait, what is this one called "marked nursing concern"? This means that if the nurse has any concern whatsoever about the patient, based on observation or instinct, s/he is authorized to call a Trigger. It turns out that this last criterion is just as valid an indicator of patient distress as the more quantitative measures. (This will come as no surprise to nurses or to those of us who highly respect their judgment!)

So how much of a difference has this made? Over the course of the past year we have have observed significant reductions in "code blue" cardiac arrest events and a significant reduction in relative risk (a 47% decrease) of non-ICU death for our patients. We are also learning a lot about teamwork, communication and systems of care as a result of closely reviewing our responses to Triggers that are called.

One side effect of this improved coordination of care and the decrease in frequency of "code blue" events is that we now need to use our simulation center to train more of our interns, residents and nurses so they can get enough experience resuscitating patients! What a lovely problem to have . . . .