Predictive Data Cuts Mortality by 30%

Yale New Haven Hospital's nurse SWAT team goes beyond just responding to changes in patients' status. It uses predictive data to anticipate problems, and intervenes at the earliest signs of decompensation.

Go with your gut. How often have you heard that advice about relationship, career, or parenting concerns?

Some of us have more accurate gut instincts than others. We get that feeling that something is right, or wrong—like when we somehow "know" to avoid an intersection just moments before an accident occurs—but we're not sure why.

I used my gut instinct often when I worked on a neuroscience unit many years ago. Sometimes something just seemed off about a patient, even though their vital signs were stable, and they knew who they were, where they were, and what year it was.

In fact, one of my strongest memories of my time there was when I called the neurosurgery team near the end of a 12-hour shift because I felt that my patient—an elderly gentleman who had slipped on ice, fallen, had a sustained a small subdural hematoma a few days prior—wasn't quite himself.

He was a gregarious guy and was quite skilled in providing non-answers to my questions by turning his responses into jokes. He managed to convince the residents, the attending, and his family that he was fine. The medical team left in a huff, annoyed at my "overreaction."

Still, as I gave my report in preparation to go home, I advised my night shift relief to "keep an eye on him because something was up." And I was right. He ended up having a seizure in the middle of the night and became combative.

Had this happened today, rather than a decade and half ago, I might have had the ability to use predictive data to support my hunch and to persuade the neurosurgeons to take action before the patient deteriorated.

The nurses at Connecticut's Yale-New Haven Hospital have been doing just that through the use of a nursing SWAT team and predictive data.

Refining Rapid Response Teams
I'd describe the way YNHH is using the combination of a SWAT team and predictive data as two steps beyond the typical use of Rapid Response Teams. RTTs came into vogue around 2005 when the Institute for Healthcare Improvement included them as one of six recommended interventions to improve patient safety during its 100,000 Lives Campaign.

These multidisciplinary groups of clinicians intervene at the bedside when a patient shows signs of deterioration. The goal is to stabilize the patient to prevent a transfer to the intensive care unit, cardiopulmonary arrest, or death. It's now possible, however, to identify subtle clinical changes earlier than ever and to intervene proactively rather than reactively, thanks to early warning scoring systems.

One of these methods is called the Modified Early Warning System, a physiological score system based on five factors: systolic blood pressure, heart rate, respiratory rate, temperature, and level of consciousness.

Another, which YNHH uses, is the Rothman Index. In addition to physiologic trends, it factors in clinical assessment data and lab results which enable clinicians to know which patients are at risk for deterioration. Because the Index interfaces with the hospital's EMR, the SWAT team nurses, who have at least a minimum of two years ICU experience and basic certifications like ACLS, can monitor real-time Rothman Index scores remotely within the hospital.

"If someone's heart rate, blood pressure, or their SAT changes, they've already started to cascade in a negative fashion," says Sheila Coonan, RN, MN, CNML. She is the patient service manager, daily operations pool, SWAT team, IV team, and nursing resources at Yale New Haven Hospital.

"When [you pull] in those other data elements, which are really nursing assessments… the patient is going to stop responding normally before their vitals change. When that person doesn't feel like eating or is a little bit more lethargic in bed, those things are really hallmarks. They're showing you that they're trending in a different way."

Real Time Equals Real Results
Diane Vorio, RN, MSN, NEA-BC, vice president, patient services, and associate chief nursing officer at Yale New Haven Hospital, shared a recent SWAT success story with me. At the beginning of one of the SWAT nurses' shifts, she was remotely reviewing her assigned units when she saw that a patient had a concerning Rothman Index score.

"The patient was in the high-risk category, which carried a 24% higher mortality rate," says Vorio. "She immediately investigated and went up to the unit only to find the patient had been sent off floor unattended to the echo lab."

She rushed to the lab and brought the patient back to the unit.

"The patient had a systolic blood pressure of 80 and needed to get a unit of blood," Vorio recounts. If it had not been for surveillance by the SWAT team, "the patient would have crashed in echo" she says.
"We averted an escalation in care to the intensive care unit, and the patient was actually discharged the next day."

This is not just an anecdotal success story. In the September 2015 issue of BMJ Quality and Safety, Coonan and her co-authors reported that they saw a 30% drop in mortality thanks to the SWAT team's monitoring of the index scores through the EMR.

Developing Clinical Confidence
Implementation of a SWAT team has other benefits as well, says Vorio, especially for new graduate nurses who, as I did, may feel their gut is telling them that something is wrong and that they need to articulate the problem to a physician.

"The nurse feels far more confident to back up her gut feeling with data—basically to call out the data," Vorio says. "Then if she's still not happy with the response, she can call the SWAT nurse."

Coonan points out that support from the SWAT team can help facilitate critical thinking skills and boost confidence and competence.

"Every time a newer nurse interacts with that SWAT nurse, I know for a fact that the next [time] they do two more steps independently, or have that two more thoughts that they're very confident on [it's] because they've been interacting with SWAT," she says. "They've learned from SWAT."

"It gives you that real level of security to be able to use data in a concrete way," Vorio says. "There's nothing worse than saying 'Boy, I should have but I didn't.'"