It’s All About Our Patients!

Alegent Health Immanuel Medical Center in Omaha, Nebraska, was among a select few hospitals that achieved the highest rankings in the CMS/Premier Hospital Quality Incentive Demonstration. Over 260 hospitals across the nation are voluntarily taking part in this three-year demonstration project. After one year, Immanuel Medical Center ranked third in the nation for acute myocardial infarction care, with a 97.87 percent quality score. http://www.cms.hhs.gov  or http://www.cms.hhs.gov/HospitalQualityInits/35_HospitalPremier.asp#TopOfPage 

“Providing outstanding patient care has always been our primary mission,” said Wayne Sensor, CEO for Alegent Health. “Our decision to voluntarily participate and publicly report our scores represents our drive to push ourselves to provide even greater quality of care.”

Dr. Fred Hosler, senior vice president and chief medical officer of Alegent Health said, “We are proud to have received such high quality scores among all of our hospitals. Our scores are a testament to the dedication to excellence of our physicians, nurses and other clinical staff.”

Clearly, this success does not just happen. It is the result of an ongoing, long standing practice of making high quality care a focus for the facility, by utilizing evidence based medicine, by actively involving the medical staff in quality activities and by using techniques such as rapid response teams.

What are rapid response teams? They are teams of two to three individuals, experienced at assessing patients’ symptoms and the trajectory of their health. A rapid response team is continuously and readily available to any provider who wants a second opinion about a patient, particularly a patient showing signs of decline. Research shows that almost all critical inpatient events are preceded by warning signs of at least several hours duration. The rapid response team is designed to intervene with patients before they develop serious medical problems. Evidence shows that use of rapid response teams can reduce morbidity and mortality, decrease length of stay, and improve patient outcomes.

Alegent Health has implemented rapid response teams, called Medical Emergency Teams (MET), on all their campuses. At Alegent Health Immanuel Medical Center, the goal is to have no codes occur outside the critical care unit. Kathryn Kohler, MSN, MBA, Quality Management Services Executive, said their team includes a charge nurse, a respiratory therapist and the patient’s nurse. To date, they have saved 50 lives (link to stories) as a result of the expertise of the MET. At Immanuel, any physician or staff person can call the MET. Changes in respiratory rate, heart rate, or level of consciousness, or the intuition of the nursing personnel that the patient ‘just doesn’t look right’ are all reasons to call the MET. To read more about Immanuel Medical Center’s policy and procedure for activating the MET.

Did the implementation of the MET at Immanuel go smoothly? “No.” said Dan Whelin, RRT and Robin Carlson, BS, RN, CCM. When they first tried to implement the MET several years ago, it failed. While working on a clinical patient safety committee looking at best practices for driving patient safety, they found the Institute for Healthcare Improvement’s (IHI) web site, www.ihi.org. The IHI Web site featured the 100,000 Lives Campaign and the use of rapid response teams as a tool to save lives. When they looked at their own rapid response team, they found it was not being utilized. They determined the reason behind the failure was the fact that they did not include the bedside nurse as a partner. The bedside nurse felt like an outsider in the treatment of her/his own patient, and felt that calling the MET would mean his/her expertise in taking care of the patient would be questioned. So they re-implemented the process in October of 2004. This time, they involved personnel from respiratory therapy, critical care nurses and med/surg nurses, administration, physicians, pharmacy and others as needed. They looked at the IHI’s policies, but decided they needed to be modified to fit the culture at Immanuel.

As they reviewed potentially preventable deaths at their facility, they identified some common themes. Failure to plan, failure to rescue, failure to communicate, and failure to recognize, were all identified as root causes. A failure to plan was defined as an adverse event that could have been avoided if planning or anticipation of the potential adverse events would have occurred. Some examples of adverse events are hypo or hyperglycemia, over sedation, and hypovolemia. Failure to communicate was defined as an adverse event that occurs as a result of a breakdown in communication. Some examples are failure to report critical lab values or vital signs, failure to communicate allergies, and failure to report changes in the patient’s condition. A failure to rescue was defined as a situation in which a patient died, and there was evidence that an intervention could have been made in the 24 hours prior to the patient’s death. Precipitating factors in the failure to rescue were determined to be a failure to plan, a failure to communicate and a failure to act. Failure to recognize was defined as those instances where the patient’s impending medical emergency was not recognized. With the assistance of IHI, Immanuel assembled several committees to review and implement change. Some of the changes that resulted included a review of all ‘code blue’ calls and all deaths, review of clinical practices that could potentially lead to a failure to rescue, development of the Medical Emergency Team, and development of parameters for vital sign reporting that could serve as an early warning to a potential medical emergency.

After Immanuel implemented the early warning system to identify patients who could potentially benefit from the expertise of the MET, they saw a dramatic increase in the number of requests for the MET. One-third of those calls resulted in a transfer of the patient to a higher level of care. They next shifted their focus to patients transferred into the ICU and looked at how many were the result of the MET and how many should have been a MET call. Two-thirds of the cases had documented signs and symptoms that should have resulted in a call to the MET. Acceptance of the MET by the medical and professional staff at Immanuel is high. Many now demand the ‘second look’ that MET provides.

To facilitate the communication process, they adopted the SBAR (Situation, Background, Assessment, Recommendation) method of documentation. This allows the bedside nurse to collect pertinent information to be shared with the patient’s physician and the MET.

• Situation = describe the patient’s condition;
• Background = briefly state why the patient is in the hospital, explain any pertinent changes in the patient’s clinical presentation;
• Assessment = give your conclusions about the patient’s condition, state how serious the patient’s condition seems to be;
• Recommendation = state what you think would be helpful.

If you have any questions or would like your hospital's quality initiatives to be featured on the NHA Web site, contact Monica Seeland, Vice President, Quality Initiatives, (402) 458-4914 or mseeland@nhanet.org.