There is a big gap world wide in hospitals between the care delivered in critical care areas and the care delivered in general patient care areas. Critical care units have all the latest toys like $38,000 patient monitors, 1:1 or 1:2 nurse to patient ratios, they deliver the most sophisticated drug therapies and can perform many surgical procedures right in the unit, delivering the most intense and expensive care.
At this conference, general care units or wards were presented as potentially less capable than hospital wards in Florence Nightingale’s day. Compared to the 1800s, there are certainly more patients cared for by fewer caregivers today. A number of presentations referred to numerous studies that reported abysmal levels of vital signs observations captured in patient charts and low levels of nursing vigilance. (All this was not to slam nurses, but to demonstrate system problems in care delivery.) Patients who experience avoidable deterioration of their condition are the patients who fall into this care delivery gap. Squeezed out by inappropriate admissions in near capacity critical care areas, patients suffer adverse events and failure to rescue occur everywhere, but especially in general wards.
Medical emergency teams (METs) were created about 10 years ago in Australia in response to unanticipated readmissions to the ICU. Jump to today, and METs and RRS (rapid response systems) are gaining mind share; most nurses in the US have heard of METs/RRS, and over 100 hospitals in the US have implemented METs/RRS, with about 1-2% of hospitals world wide also adopting this patient safety technique. There was buzz at the conference about the Joint Commission adopting some kind of patient safety requirement around METs/RRS. The process is referred to as the chain of prevention, and includes links for clinician education, patient monitoring/observation, recognition of a deteriorating condition, the call for help, and the response.
In many ways, physicians are like scientists, and are deeply connected to randomized controlled trials (or RCT’s as they referred to them – repeatedly). The outcomes from RTCs has been less than stellar, and there was quite a bit of hand wringing about the paucity of “proof” that METs or RRS actually improve care. They were all very serious, but as someone from the vendor side who’s spent 20 years working with caregivers and hospital executives, it seems the requirement for statistical proof is a red herring. The METs/RRS model is not a therapeutic intervention like a drug or surgery, it is an operation method of delivering care. What’s needed is an approach like that used in safety engineering or operations research, not a randomized multi-center double blind trial.
There was a big study that came out a couple years ago known as the MERIT study. It was a huge randomized multi-center trial that was inconclusive regarding the impact of METs on mortality. In retrospect many researchers believe that the study was flawed by what it was looking at (there are many other positive outcomes besides reduced mortality) and the subject of the trial was poorly suited for the research methods employed. There were numerous discussions about outcomes like reduced morbidity, reduced readmissions to the ICU, impacts on nurse satisfaction and retention, the number of adverse events and codes called in a hospital. But perhaps the biggest outcome for an old marketing guy like me was the impact on length of stay (LOS). Numerous studies showed significant reductions in LOS, and presenter William Ward hung his presentation on cost justification, not on reduced costs but the incremental revenue generated from resources freed up by reduced LOS.
I love the health care industry; where else can you do something that can contribute to saving peoples lives? And this conference was especially exciting because the significant impact the MET and RRS methods have on patient care. Unlike most conferences, this one was about a movement that is just taking off after many years of gestation. There was not a lot of the hard data that’s reported more mature conferences, but there was a tremendous amount of valuable information for vendors and clinicians alike.
Let me end today’s wrap up with this story. During a panel on the question of whether every patient should be on a patient monitor, a vendor asked about cost justification for more wide spread patient monitoring. In fact, some studies show that collecting data does not result in appropriate action being taken. Conference faculty Gary Smith noted that success requires both monitoring and ensuring a response (recall the “chain of prevention” above).
Pictured right is the first panel for the second and final day of the conference. None of the floors collapsed, but there were two false fire alarms.