Implementation of a Rothman index alert to facilitate MICU transfer in patients with end stage liver disease
Project Background
Patients with end stage liver disease are medically complex and may experience life threatening complications requiring transfer from a medical surgical unit to the medical intensive care unit (MICU). If clinical deterioration is not recognized early, transfer may be delayed leading to increased morbidity and mortality (Churpek et al., 2016). Currently, the alert mechanism for notifying staff of patient clinical deterioration is presented inside the electronic health record (EHR) and there is anecdotal evidence that clinicians do not see the alert unless they intentionally search for the information.
Project Purpose
The purpose of this project was to evaluate the implementation of a new electronic alert mechanism for notifying staff of a patient’s clinical deterioration. Clinical deterioration was measured by the Rothman Index (RI). The primary evaluation endpoints were use of the RI alert by the clinical team, response to the alert, time to complete a MICU transfer, and readmission to the MICU within 48 hours of discharge from the MICU.
Project Methods
The Iowa Model of Evidence-Based Practice to Promote Quality Care (Iowa model) was used to guide the project. The implementation included an educational intervention and a new mechanism for communication of the RI alert. To establish a pre-implementation baseline, patient-level data were collected on 14 MICU transfers and 19 MICU discharges from November 1 to December 31, 2017. Implementation evaluation included 11 MICU transfers and 13 MICU discharges from January 29 to March 2, 2018. Descriptive analyses using patient-focused quantitative data were completed using Stata14™. Nursing staff and medical team members assigned to care for the patients and using the new RI alert were interviewed about their perceptions of the implementation and use of the RI score in decision making. Interviews were manually reviewed with team members to validate results and identify emerging themes.
Project Outcomes
Medical staff reported no use of the RI, and nursing staff reported inability to communicate to physicians about the RI. There were no significant differences in the incidence and timing of transfers to and from the MICU after introduction of the new alert mechanism. Surprisingly, neither the baseline nor implementation group experienced MICU readmissions.
Project Implications
The findings of this project indicate the new RI-based alert mechanism had no impact on patient transfers to and from the MICU, and the current practice does not include use of the RI for patient-level decision making. While the RI has been used within the project institution for aggregate analyses, this implementation project does not indicate that the RI is used or valued for patient-level decision making. It may be possible to use the RI for surveillance and staffing decisions.
