Monday, November 08, 2010

SOS: Morse code does not predict well

Expanding on last week's post on falls, Marsha Maurer, our chief nursing officer, reports:

We've achieved fall rates at BIDMC on par with those noted in the JAMA article by using an algorithm, fine tuned over the past few years based on root cause analysis of each fall. The algorithm guides nurses to an individualized safety plan for each patient identified as "at risk" on the Morse falls tool. Of note, delirium has its own leg on the tool. It was a series of root cause analyses which identified the upstream impact of delirium on a subsequent fall that led both to this leg in the tool and the GRACE work.

We have found, however, that the Morse is a blunt tool. It over-predicts who will fall, and entirely misses some people at fall risk; for example otherwise alert, oriented and ambulatory oncology patients who become weakened over the course of chemotherapy and who overestimate their own strength. Given this, our departments of Nursing and Health Care Quality are working with the Institute for Healthcare Improvement on the next frontier of assessment and intervention -- a falls bundle. It is in pilot use now. The bundle dictates three interventions for all patients regardless of fall risk status: 1) Bed in low position -- with a clear visual cue that this is so; 2) the infusion pump on the side of the bed where the patient will exit; and 3) the call light in reach.

Concurrent with this is the use of a more clinician-friendly simple risk question: "Is this patient willing and able to RELIABLY use the call light to get help?" If the answer is "no" this puts the patient in a high risk category for falls, and additional falls prevention strategies will be implemented.

We are hopeful that this will provide a more specific and meaningful risk identification process and ultimately a reduction in the overall fall rate.


This work at BIDMC and the work cited in the previous post from Brigham and Women's Hospital are exemplary and clearly complimentary. But what is striking is the lack of coordination between the two efforts. Two Harvard teaching hospitals, separated by only a few blocks (see map), both concerned about patient safety, have had virtually no contact on this topic.

I hope I am misinterpreting, but I am concerned that this may be one of those instances in which the competitiveness among the Boston hospitals has spilt over into the safety arena. For sure, there are other areas in which information about quality of care is shared and protocols are examined together. But wherever there is a lack of discourse, opportunities for collaboration are lost. In contrast, remember our colleagues in Ohio, where the rule is, "We compete on everything, but we don't compete on safety." We owe it to our patients to adopt the same approach.


Anonymous said...

This is a problem nationally as well as locally, and many dollars and person-hours are wasted in duplicative efforts at a time when we have so much to improve, that every hour is precious. I wish the JC's Center for Transformation or whatever they call it could rapidly take more of a clearinghouse role here.

Certainly, under the rubric that all health care is local, it's a no-brainer that hospitals in the medical mecca of Boston should be able to collaborate. In addition, you should be including your poorer safety net hospitals as well as the well-appointed Harvard hospitals; so that all can benefit in a cost-effective manner.

It's too bad a place like Columbus, Ohio (no offense to them) should be well ahead of Boston. Is there no shame?


Anonymous said...

What makes it more shameful is that Harvard Medical School trains so many of these physicians, and the last that I heard, does little in the way of quality improvement education. Include Dartmouth Medical School with Ohio and others in innovation leadership.

Unknown said...

If patient safety is so high on your agenda, how come your physicians haven't adopted the Pronovost checklist?

Anonymous said...

But - aren't you the CEO? And haven't you been at BIDMC for quite a few years? If you thought that it was important for your hospital to collaborate with other local hospitals in quality improvement, why haven't you made it happen?

Anonymous said...

Anon 10:27,

By the Pronovost checklist, I assume you are referring to the protocol for avoiding central line infections. As covered elsewhere on this blog, we do indeed follow a strict protocol in this arena. The results are clear to see, in that our central line infections have virtually disappeared.

We do likewise for ventilator associated pneumonia and for the pre-surgical time out.

And we are transparent with regard to these matters. Check, under Quality and Safety to see our actual numbers.

Anon 10:59,

I was hoping someone would ask that question!

Collaboration does not get driven from the top in academic medical centers. You cannot order it to happen from the C-suite.

The collaboration that occurs happens because individual faculty members, nurses, or their leadership make the connection with people at other places. It is based on those relationships.

The fastest way to failure in these kinds of hospitals is to order people to do things.

(And besides that, look at the way you have framed the question. Even assuming your premise might have been correct, it takes two to tango. You cannot assert that it is the sole responsibility of one institution to make collaboration happen. There have to be two willing partners.)

Anonymous said...


Recently there have been some comments in the patient safety literature that it is the culture change, not just the checklist, that has effected the Pronovost improvements. An editorial in the Lancet (Aug 2009) by Pronovost himself says:

"But checklists, even if based on rigorous evidence, have never penetrated medicine in the way they perhaps ought to have. The reasons for this are primarily social and cultural. In part, the way that physicians are socialised creates resistances and interferences to the use of checklists......
The mistake of the “simple checklist” story is in the assumption that a technical solution (checklists) can solve an adaptive (sociocultural) problem."

Unfortunately, these cultural attitudes extend to the research arena where being the first to report something new gets you fame and tenure. We, including Paul and his M.D. colleagues, must now break down this sociocultural problem to achieve the collaboration needed.

My personal opinion is that it will take significant and sustained pressure from patients, who bear the consequences, for real change to penetrate the Harvard ivory tower and others.

nonlocal MD

Patti Dykes said...

The ongoing fall prevention work described by Dr. Maurer is impressive and I believe that our prospective healthcare systems can certainly learn from each other’s work.

Much has been published about the MFS and its predictive ability. Unfortunately there is no fall risk assessment tool with both 100% specificity and 100% sensitivity. Our strategy has been to rely less on the predictive “score” associated with a fall risk assessment and to pay more attention to “positive” areas of risk and then apply nursing judgment to a computer generated tailored plan. For example, one of the risk factors on the MFS is the presence of an intravenous or heparin lock. The presence of an IV/Heplock may place a patient at risk for falls for 2 reasons that if present need to be addressed in the fall prevention plan; 1)they are in danger of tripping over the pole or 2) they may be receiving some medication that leads to frequent urination. When this area of risk is selected, the Fall TIPS software will automatically select “assist with IV pole” and “provide frequent toileting assistance” as recommended interventions. Before filing the assessment, the nurse reviews the proposed plan. If the patient has a Heplock, they will deselect the “assist w/IV pole” so the corresponding icon/intervention does not appear on the bed poster, patient education handout or plan of care. If in the nurse’s judgment the patient does require frequent toileting assistance, the nurse will select the method of toileting (e.g., bedpan, commode, toilet) so the correct icon will populate the bed poster and all staff who assist that patient will know how to help that patient when they answer a call light or assist with hourly rounds. In our work we have found that using the MFS to highlight areas of risk and then apply nursing judgment to identify patient-specific interventions is a useful way to maximize the strengths of a tool while minimizing the weaknesses.

nonregional said...

Believe it or not, Heperin has a role in whether or not I comply with fall restrictions. I will do anything to avoid Heperin or the leg bands. So I want to walk no matter what. Then the nurse, who is 5 feet tall and I am not, tells me to call her before I walk. I will walk anyway, avoiding the nurse's station, so that I can tell the next shift I walked. Sorry, I know it isn't protocol!