Thursday, March 22, 2007

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 . . . .


Elliott said...

Bravo. I hope you get the word out and get other hospitals to copy your protocol. I once joked to my wife that if I ever write a book about hospital health care I would title it something like "They All Die on Night Shift".

Paul Levy said...

I received a comment today that divulges too much information about a patient to post in its entirety. Therefore, I am going to edit and put perintent parts below and then offer a separate comment afterwards.

"A friend recently told me about your blog and I had to check it out. Let me start out by saying that I am no stranger to hospitals. I have had more than my share of life threatening illnesses not only for myself, but for my son and parents as well. I have seen out of state hospitals, as well as Mass General and Boston Children’s. I have seen regular floors, step-down floors and ICU’s. My father was a patient of one of your doctors. He was very ill.

The many times we had to bring him into the ED at your hospital, my Mom, brother and myself always commented on how dirty the place was. Often seeing dry blood on the floor and no one cleaning it up after we would bring it to someone’s attention. He was extremely ill when he finally had to be admitted to the ICU. The ICU was not much cleaner than the ED. Once in the ICU, your staff, nurses, doctors, social workers, were not particularly professional. He was in your ICU for a little more than three weeks and I hated it. I hated how the staff treated my Mom and mostly I hated how they spoke to my Dad. Although he may have been in a coma, I feel he still deserved a certain amount of respect and caring. I do not believe he received it. Needless to say, my Dad passed away on from multiple infections. It has always haunted me if those infections were caused by the lack of cleanliness in your hospital. Yes, he was on chemo, he didn’t really have an immune system, that is true. But, if he was in a cleaner place, with cleaner staff, isolated sooner, would we of had at least a little more time? He caught his infections at your hospital.

So, now as I read your blog and you are “outing” your infection rates, I wonder why? Why would you do that? I have seen Mass General and Boston Children’s and [another] in Florida — all clean, very clean. If the place is clean and the staff is clean, wouldn’t those facts help lower your infection rate? Maybe you need to consider those facts and deal with the problems within your own hospital before you start comparing yourself with the other teaching hospitals that we are so fortunate to have."

Paul Levy said...

First, please accept my condolences for the loss of your father.

Second, if our folks were at all unresponsive or disrepectful to you or your family, I apologize for that. That kind of behavior is contrary to all we try to do and be.

Third, based on the personal information you included in your original comment, I have already asked my chief quality and safety officer to review the case and see what can be found and learned from it. It has now been some time, but we will review the complete record of the case.

Fourth, I do not compare ourselves with other teaching hospitals in Boston. I have questioned why they also do not post current information on their infections rates and other key quality indicators. I believe we would all be better off if we did that.

Finally, I hope I have made clear on this blog that we are trying to get better and better at what we do. To use your term, I have "outed" our infection rate, in part, so that you and others can judge our progress in improving. Also, I do it to inform people of how and why we are going about that.

Anonymous said...

It's revealing here in Paul's extraordinary web log to learn these precious bits that had been, prior, placed in the category of speculation in the minds of the very general public.

When one enters hospital the ultimate goal is to leave upright. This is both a basic and the patient's assumption. Tough noogies if some doc with ego has his or her sleep disturbed. "You called me for THAT?" should be met with, "These things come with the job. Get used to it", or better, a run up the chain of command leaving career-ending sneaker marks on the chief's sleepy and useless carcass.

From this patients' perspective, when a life is in your care it matters not if the triggers are clinical, intuitive, or a flash message from the flying spaghetti monster. One should put ones' hat on ones' head and move, not wrangle about who to wake up.

There's a clear connection between conduct, the influence of politics, and outcomes in our hospitals. Clearly it's serious: people have died because of it. I have asked before, "Where is our Department of Public Health?". There's so much work to be done. Pitifully, there is so much sloth and politic and networking getting in the way.

Thank you Paul for giving this one the light of day and, importantly, acting to change the culture.

Domenico Savatta, M.D. said...

This is a good entry.

I do most of my work out of large teaching hospitals (600+ beds), but do not have urology residents that take care of my patients. I receive all of the calls from the nurses directly because of this. I am fortunate that my robotic surgery prostate cancer patients are usually healthy and go home the next day, so major illnesses are rare.

My main question to you is how the reduced hour work week for residents has affected your safety and availability of your response team.

I was a resident 4 years ago in a busy general surgery (2 years) and then urology program (4 yeasr)with many critical patients. I have worried that less people doing more work may have an impact on safety.

This may be the topic for a different post, but I would be interested in your experience.

Anonymous said...

Referencing Elliott: When my father was dying (in a NY hospital), the interns told me that death often occurs at 4A.M. If that is not just "a young intern's tale," I commend you for providing first-rate care in the middle of the night.

ObGynThoughts said...

Dear Mr. Levy:
you are completely right with the triggers. I was surprised that you as a CEO have a blog - and a good one. May I recommend my blog to you? It is "A Physician on Job Search" and describes my experience while searching for jobs after I graduated from the BIDMC's ObGyn residency program in 99. Not that residents from "our" hospital need any help, but I am often saddened when discover how little physicians in general know about how to find the right job. It is usually considered a short, unpleasant activity, something that should be concluded quickly. Not something any reasonable physician becomes an expert in. And this turns against us, the physicians.
Thank you for taking time to read this, your Matthias Muenzer, MD, ObGyn, Medford, MA

Northern Junior Doc said...

In the hospitals I've worked in the UK if the nurses are worried about the patient the on-call 'house' doctor will assess the patient, as will a member of the ICU Outreach Team (a Senior ICU nurse) If needs be we can call the seniors (Registrars - like Fellows I believe).
The Outreach system helps alert ICU to potential 'customers' coming their way, and makes sure we do simple things well. The Outreach nurses can also set up non-invasive ventilation if we need it. A good system (if you have a good nurse!)

Paul Levy said...


Work hour rules affect lots of things (e.g., surgical hand-offs) but we have organized the floors so that there is always some one on duty, and so the response team is always available.. .

Glad to hear your robotic prostate surgeries are going well. Ditto for our manual ones! :)

edward burke said...

Paul--Your posting reminds me of the Libby Zion case in NYC about 20 years ago that led to Massachusetts legislation that would have limited house interns to no more than 75 hours a week. All of the Boston teaching hospital CEOs successfully appeared at the State House as a group to oppose the legislation. I can see that your new protocol takes some of the pressure off the intern whether to make the call to the attending doc. What if the doc is not available? Does BI have a hospitalist in-house 24 hours a day to intervene and make a treatment decision?

michael said...

For full disclosure -- I am one of the attending docs at BIDMC.

In terms of the last paragraph in Paul's post, there are some unintended effects of even a successful program like Triggers. It looks like we’re on track to have some of our interns make it through their first year without having done (or seen) CPR at the BIDMC ... definitely different than when I was an intern here. Fewer patients needing CPR is definitely a *good* thing, but it means that mannequin- and simulator-based training become even more important as the events that require CPR become rarer.

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Paul Levy said...


There is always an attending of record who can be contacted.

Anonymous said...

Although the trigger system is really a great thing, and as a nurse at BIDMC I think that it really gets people involved, and yes we have seen a lot less code blues, there are still faults in the system. I have been situations where the intern or resident has tried to talk the nurse out of calling a trigger, or disregarding the marked nursing concern. I have also been on the recieveing end of a "cancelled" trigger by the attending. Although in the end nothing happened to these patients, as soon as a nurses' concern is thrown away, what do the doctors have to rely on?

Paul Levy said...

If any nurse experiences this kind of thing, s/he should notify their nurse manager or Dr. Howell so we can follow up. There is bound to be some resistance, and it is important to nip it in the bud.

Anonymous said...

Although I applaud the trigger system as an attempt to address a known problem in the teaching hospital system, I believe there should be some feedback to hone and refine the definition of a legitimate "trigger" in terms of "marked nursing concern." As a pathologist married to an orthopedic surgeon for 30 years (nowhere near the Boston area), starting with his internship, I can testify it is no fun to have the phone ringing every hour on the hour all night. Some calls were from clearly overly concerned nurses - our personal record-holder is the call at 0100 from a nurse to tell my husband that his patient had just been discovered to have "the crabs". We have also both noticed the "I'm awake so you should be awake" syndrome on the part of some night nurses, who can go offshift and sleep the next day, unlike the docs.
If the attending or physician in training feels that the nursing concern is unjustified,perhaps the trigger should still be pulled, but then the case reviewed the next day to see if it was really legit. That way all involved learn something,and the next patient benefits, without exhausting the staff.

A said...

As a current intern, I need to make a few comments in regard to this post. There is no question that rapid response teams have had a tremendous impact on the number of codes that occur in hospitals. A reduction of 50% per annum is quite common nationally, mostly from early intervention in respiratory failure. I applaud that nurses are given the power to summon rapid response teams as they spend the most 1:1 time with patients and are frequently first to see clinical deterioration.

I would caution against the implied conclusion that intern/resident care at night leads to worse outcomes. Retrospective lenses when looking at individual cases can falsely exaggerate root causes of failure...particularly when emotions are involved. Interns get called dozens (sometimes nearly a hundred) of times a night for various cross cover queries. Undoubtedly, there are errors that are made but in my experience, few decisions would have altered the treatment plan. Sometimes a patient needs time to "declare" how significant a change in clinical status actually is. My guess is that in the rare adverse event root cause analysis, interviewed parties remember the intern assessment as being the critical decision point mainly because their assumed inexperience and assumed lack of oversight. This bias may not be appreciated during the daytime because of assumed closer oversight.

I would propose a natural study. Continue rapid response teams hospital wide. Limit "triggers" to certain units / floors and compare code rates between trigger and non-trigger floors. My gut is there would be no significant difference since the major intervention (rapid response teams) likely accounts for all of the code rate improvement.

If I'm wrong, I'll let my attending know.

Paul Levy said...

Dear a,

Before implementing triggers throughout the hospital, we conducted an 1845-patient day trial in which we instituted triggers on a couple of floors and left things without triggers on comparable floors. It was the result of that natural experiment that caused us to go ahead. There was a statistically significant difference in outcomes between the two types of settings.

But, we continue to review individual cases to look for possible flaws in methodogy, trends, etc.

We did not enter into this with the expectation that it is necessarily intern inexperience that causes problems. It sometimes is, sometimes isn't. But it is often helpful to have a more seasoned point of view at the bedside.

Finally,on your point:
"Undoubtedly, there are errors that are made but in my experience, few decisions would have altered the treatment plan. Sometimes a patient needs time to 'declare' how significant a change in clinical status actually is." Well, maybe, but our data indicate that just the opposite is often the case. As a patient, I'd rather someone intervene earlier than later, just in case. The cange in mortality rate in our medical/surgical units seems to me to be pretty persuasive.

You seem very defensive on the point I raised about intern inexperience. Look, they ARE inexperienced. This program offers them (and the patient) a safety net.

Paul Levy said...

Dear Anon 11:44PM,

The data in our hospital indicate that the triggers called as a result of "marked nursing concern" are often the most valid. I have neard no feedback of the type you mention from the senior nurses or the attendings. Certainly none of the "I'm awake so you should be awake" attitude. It is hard to imagine that kind of attitude among our nurses.

Also, as mentioned above, we review all trigger cases after the fact to learn from them, and we share interesting conclusions with all of the staff.

BipolarLawyerCook said...

Bravo for your Triggers program. Like any system, it will be refined as you find out what works and what doesn't, but the middle-of-the-night decompensation phenomena is entirely real, and the fact that BIDMC is doing something about it is impressive. I used to defend med mal cases, and the middle-of-the-night cases were the hardest to defend, and the most frequently settled-- because someone in the chain of providers made a mistake in not calling an attending, or an attending didn't check in as often as they ought, given the intern or MS3/4 on duty. As a DPH investigator said in one particular parade of horrors-- "it's a patient, the buck stops nowhere."

Christine said...

I would like to thank you for your response in your blog. I really hadn't expected you to post anything. I am glad to hear you are trying to improve. My Dad was a teacher and would be quite satisfied if our experience could continue as part of an educational process. Good luck.
Christine Rice