#34 - Patient Deterioration with Humber River Hospital's Dr. Susan Tory, Jane Casey and Jhanvi Solanki

Jeff Terry:

Before we jump in, let's quickly orient the audience to the clinical deterioration tile. You see a screen grab of a tear, of course, with fake data. Each of these rectangles is a patient who either has an elevated early warning score, or their early warning score is changing quickly. And of course, Humber determines what scores and what rates of change they want to appear here. And the early warning score itself is calculated in the EMR. We're just surfacing that and organizing it in an easy to use way here. Below the early warning score, you'll see that some of those are alerting for time, which is how long has it been since the last full vital sign assessment on that patient, and Humber has set alerts based on if it's been longer than they would like, based on certain scores for the patient.

To the left of that, you see a series of pills for the different vital signs, and those are color coded by how much they're contributing to the early warning score. I can click on any pill or hover over it, and it'll give me a list of when that vital sign was recorded and what the value was. Over to the left of that in each rectangle, I see the patient name, alias, location, and below that, icons for COVID, waiting for test, PUY negative, or positive, it will appear if the patient is septic and to the right of that, a little medical case that appears, and it tells me when was the last time a nurse, a physician, a pharmacy tech, any clinician was involved with that patient, and that can turn different colors based on the frequency of that activity.

Along the bottom, we see the census of high-risk patients, to the very left that are being followed by the rapid response team, and then the medicine service surgery paeds, and the SP means that someone has an elevated single parameter, then how many patients have a score of five or six. How many patients have a score of seven plus. And if I hover on any of those numbers, it'll give me a list of those patients, their alias, location, et cetera. Of course like any tile I can go to the right click on the gear and apply filters for my unit or show me only patients with certain goals of care, quite a few different ways that each user can tune the tile. So that's the tile. And with that, let's get into the conversation.

Hello and welcome. I'm Jeff Terry, delighted to be joined today by Jane Casey, Dr. Susan Tory, and Jhanvi Solanki from Humber River Hospital. Good morning everyone.

Susan Tory

Morning.

Jeff Terry

So we're going to talk today about the Clinical Deterioration Tile at Humber River Hospital. Of course, Humber River Hospital is a hotbed of innovation, operationally, clinically, and in patient experience, and this work is just one example of that. The team here are the pioneers of this work. So we'll try to unpack it.

Dr. Tory, if I could start with you, what's the purpose of the Clinical Deterioration Tile? Why did you do it?

Susan Tory

Thanks, Jeff. We wanted to really translate the work that had been done already in the implementation of our command center, where we are so fortunate to operate in a very data rich environment here at Humber River Hospital, being a fully digital hospital. And we'd seen such immense success with the implementation of the first generation of the command center pertaining to mitigating delays and inefficiencies with respect to operations surrounding patient flow in the hospital.

So the vision had always been there to really transition a lot of that work and translate it into driving high reliability care, which is what we strive for at Humber. And what we wanted to do is utilize the data that we have as well as analytics to really backstop and underscore patient safety and quality of care here at Humber River Hospital.

The design of the Clinical Deterioration Tile is looking at physiologic parameters for our patients, which are gathered throughout the day upon every assessment of a patient's vital signs and level of consciousness by our nursing staff, using their bedside monitors, and really driving that through analytics into a clinical deterioration or early warning score.*

 *The Clinical Deterioration Tile presents and aggregates information gathered from other systems to improve visibility and workflow efficiency, based on hospital defined standards. It does not make clinical determinations and is not intended for patient monitoring.

Over the past 3 years Humber River was able to create 35 beds of capacity without the need for additional infrastructure or staff by driving more efficiency thanks to their Command Center".

So what we designed at Humber was a score that was initially based on the NEWS 2 score out of the U.K., but really then we're able to refine and adjust it based on our patient population and our staff's clinical experience with using the score to be able to consolidate that information into a meaningful way to monitor our patients both up at the unit level and at the bedside, as well as from the command center to really provide that additional piece of recognition, that additional point of conversation around patient care that really prompts the frontline staff, the clinicians, to always be thinking about how our patients are doing, if there is a trend towards a certain direction we want to try and intervene or intercept, really to prevent the never events in the hospital, such as requiring ICU admission, a code blue, or any other form of patient morbidity or mortality.

And so that was the thought process behind the design of this Tile. And really, in its inception, wanted to heavily, heavily involve our clinicians to make sure that the input that they wanted to factor in what they wanted to see.

Jeff Terry

Easy to use for that. It makes total sense. So we're going to unpack that. Thank you. Jane, Dr. Tory touched on this a little bit. Could you expand? So this is one piece of the program. How does the clinical deterioration work fit with the overall command center?

Jane Casey

Well, the overall command center really supports our strategic plan, which is what Dr. Tory eloquently said about being a higher liability hospital, being all about patient safety and all about that quality and not having the never events. We call it, it's like our safety net. It's there to help, it's just to support that frontline staff, just to have another set of eyes, to be seen if a patient's deteriorating and how can we support. And what's really nice is that if a patient's deteriorating at 2:00 in the morning or at 8:00 in the morning, there's always someone there to go and help and support.

So really, this Tile, as all of our Tiles, support our strategic plan and the goal of the hospital, which is just to give that patient the best experience we can give with the best outcomes.

Jeff Terry

Brilliant. Thank you. Jhanvi, what's been the impact so far of this work?

Jhanvi Solanki

Clinical deterioration is one of those interesting concepts because when you look at the medical legal literature and you look at the experiences around when patients deteriorate in hospital, clinical deterioration is one of those interesting complex systems. It's quite multifactorial. There's an element of unpredictability and there's multiple systems involved, multiple individuals involved. And like Dr. Tory said, part of what we try to do with this Tile is really trying to simplify that piece. The impact of the clinical deterioration work has really been to increase accountability and awareness across the organization.

There's a couple of different themes along the clinical deterioration thread, and what literature tells us is about 40% of times it's clinicians that are not aware. They don't have that situational awareness in recognizing first that the deterioration is occurring. And then the second delay that occurs once that deterioration has been recognized, the intervention around it.

One of the easiest metrics for hospitals really to look at is the number of code blues. What we saw with this Tile within four months of implementation was that our rate of code blues went down. We saw a reduction by 47%. So about 18.8 code blues per month to down to 10 code blues. And that's really important because that's a significant reduction in that clinical deterioration activity happening on the medicine or the surgical ward. And what that actually does is it actually helps us understand that we are able to identify a trigger that a patient is deteriorating, align the right resources, and get the patient the right type of care that is needed and the right place. That may be ICU, that may be the operating room, whatever the interventions necessary may be. But realistically, our job as hospitals is really to ensure that we prevent that clinical deterioration and that we ensure that when patients are admitted that they have a very positive trajectory or a positive outcome based on their prognosis and their diagnosis.

In terms of the accountability piece, one of the other aspects is human behavior. That really impacts how clinical deterioration is recognized. And as we looked at the NEWS 2 score and we started to embed it, we did multiple time studies and looked at how it was actually impacting our staff. We looked at are they actually able to interpret the information correctly? And then we went back to the drawing board, and that's how the Humber River early warning score was conceived.

There's very specific timeframes for vital signs. And what the clinical deterioration Tile does is it actually allows us to identify that on the Tile itself for the sickest patients in the building. So if we're missing vital signs at the right frequency or at the right duration, then the Tile actually generates an alert. And that alert then generates and prompts action, which is the most important part about that accountability piece. And as we go on, we'll talk more about how that accountability piece works, but the other big aspect around this is the integration with the care team and just spreading that communication around that situational awareness.

Jeff Terry

That's brilliant. And just to give it one more layer of detail there on how. So for the nursing team, what does use look like in practice? How does it integrate with the workflow as you mentioned?

Jhanvi Solanki

So in terms of the workflow, integration is a very important word at Humber River Hospital. That is because we are so data-driven and we are so paperless.

One of the foundational thoughts behind the medicine surgical units at Humber was automatic data entry. So from the time that the vital sign machine is hooked up to a patient, and we actually take that set of vital signs, that information should go directly into the EMR. And we really maximize that concept here with the early warning system, because what we did was we actually built our early warning scoring system directly into our vital sign monitors. So right at the bedside, when the nurse attaches the vital sign monitor to the patient and runs the set of vital signs, they get their early warning score and the actions that are warranted for that patient right on their vital sign monitor itself, which prompts them for the documentation action, and all of that is all documented right there at that minute. And that feeds into the command center. And that type of real-time data actually allows us to intervene in a much more timely fashion. Because if there is something occurring on the floor and the floor requires support, then the clinical expediter can jump in as well.

Jhanvi Solanki

The other aspect about the nursing workflow is the charge nurses and the clinical practice leaders and the clinical managers. So one of the interesting aspects about this Tile is within my clinical areas, and I'll speak to maybe surgical services, this Tile has been integrated into our bullet rounds. So the acuity score for Humber River early warning score, the RP actually pulls up, our resource nurse actually pulls up the Tile and they actually review two aspects. They review the inpatient unit Tile, as well as the Clinical Deterioration Tile, and they follow the acuity of the patient based on that. Because in surgery, our patients deteriorate, when they deteriorate, they deteriorate quite quickly and require operating room intervention. So that integration has really, really helped with regards to monitoring acuity and how the entire team can come together and have that conversation.

One of the other aspects about that acuity piece is because it is a conversation with the leadership, frontline nursing and the resource nurse all at the same time, the team can intervene right away, the managers and the clinical practice leaders to help and help support that nurse. So sometimes we might have to change the ratio because of acuity, because their patients are deteriorating quite quickly and lots going on. And in order to generate that safety piece, we do need to actually reduce our ratio maybe down to one-to-one or two-to-one. And that kind of setting allows us to do that.

Jeff Terry

That's great. That's a brilliant perspective of the rounding, how it's used by the teams all the way to staffing. Dr. Tory, I want to come back to you for the physician perspective [inaudible 00:11:24]. So how is it used by the physician team?

Susan Tory

Yeah, so as Jane and Jhanvi alluded to, part of ensuring that there was going to be usage uptake socialization of this Tile was making sure there was significant ongoing heavy involvement of physicians in its development, rollout, and carry forward. And that was a huge component of it, and it goes along the theme of how Humber has really embraced the command center concept and really kind of adopted it as just the digital hub of the hospital.

So in terms of its actual practical usage from day to day for physicians, I think the biggest driving force that this Tile has created is just, as I said, allowing more conversations around the clinical picture of each patient. What we learned was when we implemented this score, there are lots of patients within our organization who will flag high on the early warning score system. And really, what it wants to drive is perhaps that patient doesn't need an immediate action, an immediate transfer to ICU or to OR, but what it needs is closer attention and a conversation around what might be driving that score.

And I think the other piece is that it's always reminding us as clinicians to think sepsis, and to say, "Is there something else developing? Is there a complication developing or present that's driving this score?" And the rate of change of the score and the direction in which it's changing has also been something that is obviously very clinically relevant to the attending physicians.

And I think that what we've tried to achieve as well is to really drive the sensation of ownership amongst the clinical staff nurses and physicians of the command center Tiles. And Jane will allude to, I think, a little bit more about how accessible these Tiles have been to everybody around Humber, to be able to look at any point and see what's going on on the deterioration Tile and to filter it however you want for your own patients, for your own unit, geographically, whatever. And that easy access has really also driven a lot of interest in the command center and a lot of interest in a lot of this clinical monitoring work that we're doing.

The last thing I'll say that I think really made this a very physician-friendly initiative is that... I think nurses can attest to this as well. Like being in a digital hospital, there's a lot of computer charting. There's a lot of different screens that we look at and document on. And one of the beauties of the command center is that it's that consolidated information. It's a one look, one-stop shop to get very clinically important details on this Tile that really help drive decision-making for me as a physician. So I can see their early warning score. I can see how long ago their last set of vitals was taken. I can see if the critical care response team is following or has seen them recently. And most recently we even added an indicator to see if the patient is COVID-19 positive or not, because we know that this has an impact in how we're going to manage the patient.

So the benefit of having the efficiency of looking at one screen, one Tile to see a lot of very important data, including relevant laboratory investigations and so on, has really stood out as being a difference maker for physicians.

Jeff Terry

That's brilliant. Easy, consolidate information, filter to what you want to see obviously for the busy clinicians, nurses, and physicians. And so, Jane, Susan alluded to this, but can you expand on that? We've heard two perspectives. What about from the leadership perspective and how it's used in the command center itself by the team there?

Jane Casey

Thank you very much, Jeff. So definitely, this Tile, as the other Tiles, it's the pulse of the hospital. It's what we really want to monitor. And our focus is how can we get the frontline staff and physicians to be with the patients? And what can we do to help support so that they've got the information right in their hands?

We've added a clinical expediter role. It is a very experienced registered nurse, and they watch those boards 24 hours a day, seven days a week. So at 6:00 in the morning there is that same support as there would be on a Friday at 11:00. So that's been a great help.

The other thing is, this is our lifeline. I know in my office, I have this up and I'm constantly looking at it as other leaders and chiefs are, and we're helping support. We also collect data. There's a ton of data that comes available, and I'll give you an example. We really looked at the acuity on some of these units, and we looked at what time of day, and we did have some extra resources about a year ago. We use this as part of our basis to add an additional nurse on nights on the medicine floor, because it became very, very clear that this is what was needed.

We also realized that our staff do a lot of partial vital signs. And I get asked quite a bit, "Oh, that doesn't happen at my place of work." And I sit there going, "But I didn't think it happened here either." And so once we found out that there's a lot of partial vital signs, we had the support of the organization that a whole simulation education day was devoted. We do education days every year. The organization said, "This year, we're going to do a simulation with our frontline staff, all related to deterioration and how to rescue these patients. And what can we do? And help with their assessment skills, et cetera." So that's what we did.

So the Tile is, yes, the clinical expediter helps, but it's also the leadership team. And when I say leadership, I mean, all the physician chiefs, all the directors, the managers, they're all looking at this information, and it's really spearheading what improvements can we do for patient care here at Humber?

Jeff Terry

That's brilliant. And just for our audience quickly to unpack, a piece of what you mentioned is clear there's the real-time information, maybe where right now haven't we done a full vital sign assessment as frequently as we'd like, and then there's also the learning loop. Wait a minute, there's a pattern of deterioration. There's a pattern of whatever, which we can learn from the accumulation of that real-time data. Is that right?

Jane Casey

It's exactly right. Thanks very much, Jeff. And I also say that pattern data came back not how I thought it was going to come back.

 Jeff Terry

Which is, that's learning. Right?

Jane Casey

We've been pretty good at night. I thought we didn't do very good at night, but we actually do pretty good. So it really helped us to target how can we help support the staff and what's going on, so that they can provide that exceptional care that we want for every single patient

Jeff Terry

That's brilliant. Jhanvi or Dr. Tory, any last comments on the learning loop or other uses of the Tile you want to mention?

Jhanvi Solanki

I think one of the pieces that I just want to comment on is the culture at Humber River Hospital is a little bit different than most other hospitals that I've worked. I know we talk about in lots of different textbooks that we need to have a culture of innovation and a culture of learning. Realistically, it's very hard to build that culture, and it is very difficult to execute it, especially when it's a very theoretical concept. And the reason I'm belaboring that a little bit is because having lived that through the Clinical Deterioration Tile and the work and with my two amazing colleagues, Susan, Jane, and the GE team, I think we were able to build that culture of innovation and that learning culture at Humber.

And as we continue on this journey, it's going to look different. I have to say that I'm very proud to be part of this culture of innovation, where what we do in the command center isn't just what we do within the confines of the command center. But the command center is more so... It's more so an entity that actually lives in every unit and in every corner. And it doesn't control the organization, but it drives the organization to where we want to be today.

Jeff Terry

That's brilliant. And we're honored to be on this journey with you. Dr. Tory, a final thought?

Susan Tory

I think just based on what Jhanvi alluded to, it's just that as an organization and as a hospital together with all levels of staff, nursing, allied health physicians, housekeeping, we all had to come together and adapt to the concept of a command center where initially frankly people were wary of it. But I think that really everyone has come along to learn that although a data rich environment leads to transparency, for better or for worse, people have come along to really fear it less and to be less apprehensive about that transparency, and to embrace it more as an opportunity to learn from it. And I think that's where we've been able to capitalize on the implementation of the clinical deterioration. As Jane said, you see patterns, and you see how we are doing things. And although it might've felt like the status quo before, if it needs to be tweaked, adjusted, or totally blown up, this is the evidence to show us which direction we need to point ourselves in to have a better outcome and a better quality of care and experience for our patients.

So it has come with the understanding that this group of people at Humber is ready to embrace and embark on whatever adjustments and improvements are needed, but we're fortunate to work in an environment where people seem quite ready to do that.

 Jeff Terry

Well, and the proof's in the pudding. Right? These different innovations are working, which I'm sure builds momentum and trust to keep going.

Wonderful. Well, thank you all so much. We love working with you and for you. Thank you for joining the podcast today. And I think with that, I'll close the podcast.

Disclaimer: “Tiles present and aggregate information gathered from other systems to improve visibility and workflow efficiency, based on hospital defined standards. Tiles do not make clinical determinations and are not intended for patient monitoring”