Hospitals try to break a deadly 'code' LONG

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Hospitals try to break a deadly 'code'


Rapid response teams helping to save lives

By Liz Kowalczyk, Globe Staff  |  November 27, 2005

Every year, thousands of patients suffer a cardiac or respiratory arrest
in what seems like the best possible spot, the place most likely to
guarantee their survival: A hospital bed. But despite their proximity to
nurses, doctors, and life-saving medical equipment, more than 80 percent
of patients who ''code" in the hospital die before going home.
Dr. Michael Howell, an intensive care specialist at Beth Israel
Deaconess Medical Center, said studies have started to provide clues as
to why: In some cases, caregivers took too long to recognize the danger
signs and, as a result, delayed potentially life-saving treatment. The
problem may be worsening, as more bedside nurses on regular floors
outside of intensive care units are fresh out of school and without the
experience to recognize subtle warnings.

''It's a failure to give patients the best shot," Howell said.
After studying the approach of Australian hospitals that say they have
reduced patient mortality by one-third, Beth Israel Deaconess last month
became one of a growing number of US hospitals to establish a special
rapid response team that aims to recognize warning signs sooner and
prevent patients from arresting. Holyoke Medical Center established such
a team last year, and Brigham and Women's Hospital will begin testing
the concept on its 14th floor medical unit on Dec. 5.
Howell hopes the team will prevent delays like one he described to the
Beth Israel Deaconess board of directors last month: Doctors admitted an
elderly man to the hospital for gastric bleeding. When his systolic
blood pressure dipped into the 80s, his nurse and an intern gave him
intravenous fluids to push it back up to normal range. His pressure
climbed back into normal range. Over the next eight hours, the patient's
blood pressure kept falling, and they kept pumping in fluids. Low blood
pressure is generally not life threatening until it dips into the 70s or
60s. But they failed to recognize that the subtler decline masked a more
serious underlying problem: massive stomach bleeding. The next morning,
a senior doctor did, and transferred the patient to the ICU, which has
the staffing expertise and equipment to intervene more rapidly. But it
was too late.

''I don't know that we would have saved him," Howell said. ''But it's
absolutely possible."
Now, when a patient's condition worsens in one of six specific ways,
including systolic blood pressure that dips below 90, or when a nurse
has marked concern about a patient, the nurse is required to set into
motion a series of events called a trigger. The nurse pages a special
team -- including a senior nurse, an intern (a first-year doctor), and a
respiratory therapist if it's a breathing problem -- immediately to the
patient's bedside. The intern is required to notify the resident, who is
required to call the attending doctor, or senior physician.Continued...
Previously, it was up to nurses to decide whether to call in
reinforcements. And even when they did, interns at times gave
instruction over the phone and did not come see the patient right away.
''At night, when something happens, you ask yourself, 'Is this really
important? Is it really worth bothering a doctor?' " said Rose Segura,
33, a nurse on one of Beth Israel Deaconess general medical floors for
one year. ''This makes it crystal clear there are situations that need
to be addressed. It's a way of reaching up the chain of command to more
experienced people to make sure you're doing the right thing."
Not everyone is convinced.
Australian hospitals were among the first to adopt medical emergency
teams to intervene before cardiac or respiratory arrests, or to transfer
patients to the ICU. One hospital reported in a study last year in the
journal Critical Care Medicine that establishing such a team reduced
mortality among post-surgery patients by 36 percent. Several US
hospitals have reported similar results.
But in a study published in June in the Lancet, Australian researchers
compared 12 hospitals that introduced these teams with 11 hospitals that
did not. Surprisingly, both groups reduced deaths, cardiac arrests, and
unplanned ICU admissions by about one-third. It's possible, Howell and
other doctors said, that the latter group improved care to patients
simply because doctors and nurses knew they were being closely watched
as part of the study.
Because of these results and because of the cost of extra nurses and
doctors to serve on the teams, Brigham and Women's scrapped plans for a
hospital-wide rapid response team this summer and decided to move more
slowly. ''We need to find out is this really going to make a
difference," said Dr. Andy Whittemore, the hospital's chief medical
officer.
Beth Israel Deaconess will study whether there are fewer unexpected
deaths among patients after adopting the team. One issue is whether the
hospital's trigger teams can match the results of the Australian and
other US teams, which generally include doctors or nurses trained in ICU
care.
''A trigger is not about excitement and drama; it's about intervening
before there's drama," Jeanne Quinn, a senior nurse, said Tuesday
morning during break on a unit for post-surgery and trauma patients.
Minutes earlier, Judy Wagoner, a 29-year-old nurse with 2 1/2 years
experience, had activated a trigger when her patient's blood pressure
plunged to 56.
As the senior nurse on the floor, Quinn responded and helped Wagoner
gradually raise Carol Emerson's pressure back into the 100s. The team
ordered an electrocardiogram to rule out underlying heart problems and a
blood transfusion, and kept the patient an extra night. About 80 percent
of the nurses on the floor have less than two years' experience, while
Quinn has 15.
No one knows for sure if early intervention helped Emerson, who was in
the hospital so surgeons could repair broken bones in her left arm,
avoid cardiac arrest. And Wagoner said she would have asked for Quinn's
help even before the new rules.
But doctors believe the key to reducing patient mortality is to
intervene at the first sign of trouble, before the patient ''arrests,"
an emergency involving the heart or lungs -- or both-- shutting down.
According to a 2003 study of 14,720 cardiac arrests in 207 US hospitals,
only 17 percent of patients survived to discharge. Even some top-level
academic medical centers do only slightly better. Brigham and Women's
saves about 24 percent of patients who suffer an arrest, doctors there
said.
Howell said it's so difficult to save these patients because their
bodies already have begun shutting down. Within four to six minutes of a
cardiac arrest, a person's brain cells start dying and the other organs
stop working.
Some of these patients are so sick with underlying heart disease or
other serious illnesses or trauma that they will die no matter what
doctors and nurses do. But in a 2002 British study, researchers found
that 68 percent of 118 cardiac arrests in one hospital could have been
prevented; in almost half the cases, caregivers did not act on a warning
sign that the patient's condition was deteriorating, including low blood
pressure or a deepening coma.
US hospitals that use rapid response teams are reporting better
outcomes. At the University of Pittsburgh Medical Center Presbyterian,
the cardiac arrest rate dropped to 4.5 of every 1,000 patients in 2000
from 6.8 the previous year, and patient mortality fell 30 percent, said
Dr. Michael DeVita, an intensive care physician and associate medical
director of the hospital.
But even at Beth Israel Deaconess, some staff members resisted the shift
in culture -- at least initially. Dr. Inga Lennes and Dr. Amanda
Pressman, both third-year residents, worried the program would create an
avalanche of extra paperwork. ''We didn't want to lose our autonomy,"
Lennes said. ''We didn't want a system where all of these important
decisions are taken out of our hands and moved up the chain of command."
Howell, who supervised them when they were interns, told them the
hospital was going to adopt the teams, so they should find a way to make
it work. The two women decided to survey interns and residents about
their experiences on the teams and hold extra teaching sessions on how
to evaluate and treat patients with potentially dangerous warning signs.
They are starting to see benefits: Now, when nurses call interns and
residents about a problem on the trigger list, the doctors know they
must drop what they're doing and see the patient. ''No one is arguing
anymore," she said. ''It's the policy."

Liz Kowalczyk can be reached at kowalczyk@xxxxxxxxxx
Copyright 2005 Globe Newspaper Company.
Hospitals try to break a deadly 'code'
Rapid response teams helping to save lives
By Liz Kowalczyk, Globe Staff  | 
November 27, 2005
Every year, thousands of patients suffer a cardiac or respiratory arrest
in what seems like the best possible spot, the place most likely to
guarantee their survival: A hospital bed. But despite their proximity to
nurses, doctors, and life-saving medical equipment, more than 80 percent
of patients who ''code" in the hospital die before going home.
Dr. Michael Howell, an intensive care specialist at Beth Israel
Deaconess Medical Center, said studies have started to provide clues as
to why: In some cases, caregivers took too long to recognize the danger
signs and, as a result, delayed potentially life-saving treatment. The
problem may be worsening, as more bedside nurses on regular floors
outside of intensive care units are fresh out of school and without the
experience to recognize subtle warnings.
''It's a failure to give patients the best shot," Howell said.
After studying the approach of Australian hospitals that say they have
reduced patient mortality by one-third, Beth Israel Deaconess last month
became one of a growing number of US hospitals to establish a special
rapid response team that aims to recognize warning signs sooner and
prevent patients from arresting. Holyoke Medical Center established such
a team last year, and Brigham and Women's Hospital will begin testing
the concept on its 14th floor medical unit on Dec. 5.
Howell hopes the team will prevent delays like one he described to the
Beth Israel Deaconess board of directors last month: Doctors admitted an
elderly man to the hospital for gastric bleeding. When his systolic
blood pressure dipped into the 80s, his nurse and an intern gave him
intravenous fluids to push it back up to normal range. His pressure
climbed back into normal range. Over the next eight hours, the patient's
blood pressure kept falling, and they kept pumping in fluids. Low blood
pressure is generally not life threatening until it dips into the 70s or
60s. But they failed to recognize that the subtler decline masked a more
serious underlying problem: massive stomach bleeding. The next morning,
a senior doctor did, and transferred the patient to the ICU, which has
the staffing expertise and equipment to intervene more rapidly. But it
was too late.
''I don't know that we would have saved him," Howell said. ''But it's
absolutely possible."
Now, when a patient's condition worsens in one of six specific ways,
including systolic blood pressure that dips below 90, or when a nurse
has marked concern about a patient, the nurse is required to set into
motion a series of events called a trigger. The nurse pages a special
team -- including a senior nurse, an intern (a first-year doctor), and a
respiratory therapist if it's a breathing problem -- immediately to the
patient's bedside. The intern is required to notify the resident, who is
required to call the attending doctor, or senior physician.
''At night, when something happens, you ask yourself, 'Is this really
important? Is it really worth bothering a doctor?' " said Rose Segura,
33, a nurse on one of Beth Israel Deaconess general medical floors for
one year. ''This makes it crystal clear there are situations that need
to be addressed. It's a way of reaching up the chain of command to more
experienced people to make sure you're doing the right thing."
Not everyone is convinced.
Australian hospitals were among the first to adopt medical emergency
teams to intervene before cardiac or respiratory arrests, or to transfer
patients to the ICU. One hospital reported in a study last year in the
journal Critical Care Medicine that establishing such a team reduced
mortality among post-surgery patients by 36 percent. Several US
hospitals have reported similar results.
But in a study published in June in the Lancet, Australian researchers
compared 12 hospitals that introduced these teams with 11 hospitals that
did not. Surprisingly, both groups reduced deaths, cardiac arrests, and
unplanned ICU admissions by about one-third. It's possible, Howell and
other doctors said, that the latter group improved care to patients
simply because doctors and nurses knew they were being closely watched
as part of the study.
Because of these results and because of the cost of extra nurses and
doctors to serve on the teams, Brigham and Women's scrapped plans for a
hospital-wide rapid response team this summer and decided to move more
slowly. ''We need to find out is this really going to make a
difference," said Dr. Andy Whittemore, the hospital's chief medical
officer.
Beth Israel Deaconess will study whether there are fewer unexpected
deaths among patients after adopting the team. One issue is whether the
hospital's trigger teams can match the results of the Australian and
other US teams, which generally include doctors or nurses trained in ICU
care.
''A trigger is not about excitement and drama; it's about intervening
before there's drama," Jeanne Quinn, a senior nurse, said Tuesday
morning during break on a unit for post-surgery and trauma patients.
Minutes earlier, Judy Wagoner, a 29-year-old nurse with 2 1/2 years
experience, had activated a trigger when her patient's blood pressure
plunged to 56.
As the senior nurse on the floor, Quinn responded and helped Wagoner
gradually raise Carol Emerson's pressure back into the 100s. The team
ordered an electrocardiogram to rule out underlying heart problems and a
blood transfusion, and kept the patient an extra night. About 80 percent
of the nurses on the floor have less than two years' experience, while
Quinn has 15.Continued...
No one knows for sure if early intervention helped Emerson, who was in
the hospital so surgeons could repair broken bones in her left arm,
avoid cardiac arrest. And Wagoner said she would have asked for Quinn's
help even before the new rules.
But doctors believe the key to reducing patient mortality is to
intervene at the first sign of trouble, before the patient ''arrests,"
an emergency involving the heart or lungs -- or both-- shutting down.
According to a 2003 study of 14,720 cardiac arrests in 207 US hospitals,
only 17 percent of patients survived to discharge. Even some top-level
academic medical centers do only slightly better. Brigham and Women's
saves about 24 percent of patients who suffer an arrest, doctors there
said.
Howell said it's so difficult to save these patients because their
bodies already have begun shutting down. Within four to six minutes of a
cardiac arrest, a person's brain cells start dying and the other organs
stop working.
Some of these patients are so sick with underlying heart disease or
other serious illnesses or trauma that they will die no matter what
doctors and nurses do. But in a 2002 British study, researchers found
that 68 percent of 118 cardiac arrests in one hospital could have been
prevented; in almost half the cases, caregivers did not act on a warning
sign that the patient's condition was deteriorating, including low blood
pressure or a deepening coma.
US hospitals that use rapid response teams are reporting better
outcomes. At the University of Pittsburgh Medical Center Presbyterian,
the cardiac arrest rate dropped to 4.5 of every 1,000 patients in 2000
from 6.8 the previous year, and patient mortality fell 30 percent, said
Dr. Michael DeVita, an intensive care physician and associate medical
director of the hospital.
But even at Beth Israel Deaconess, some staff members resisted the shift
in culture -- at least initially. Dr. Inga Lennes and Dr. Amanda
Pressman, both third-year residents, worried the program would create an
avalanche of extra paperwork. ''We didn't want to lose our autonomy,"
Lennes said. ''We didn't want a system where all of these important
decisions are taken out of our hands and moved up the chain of command."
Howell, who supervised them when they were interns, told them the
hospital was going to adopt the teams, so they should find a way to make
it work. The two women decided to survey interns and residents about
their experiences on the teams and hold extra teaching sessions on how
to evaluate and treat patients with potentially dangerous warning signs.
They are starting to see benefits: Now, when nurses call interns and
residents about a problem on the trigger list, the doctors know they
must drop what they're doing and see the patient. ''No one is arguing
anymore," she said. ''It's the policy."

Liz Kowalczyk can be reached at kowalczyk@xxxxxxxxxx
Copyright 2005 Globe Newspaper Company.


Hospitals try to break a deadly 'code'
Rapid response teams helping to save lives
By Liz Kowalczyk, Globe Staff  | 
November 27, 2005
Every year, thousands of patients suffer a cardiac or respiratory arrest
in what seems like the best possible spot, the place most likely to
guarantee their survival: A hospital bed. But despite their proximity to
nurses, doctors, and life-saving medical equipment, more than 80 percent
of patients who ''code" in the hospital die before going home.
Dr. Michael Howell, an intensive care specialist at Beth Israel
Deaconess Medical Center, said studies have started to provide clues as
to why: In some cases, caregivers took too long to recognize the danger
signs and, as a result, delayed potentially life-saving treatment. The
problem may be worsening, as more bedside nurses on regular floors
outside of intensive care units are fresh out of school and without the
experience to recognize subtle warnings.
''It's a failure to give patients the best shot," Howell said.
After studying the approach of Australian hospitals that say they have
reduced patient mortality by one-third, Beth Israel Deaconess last month
became one of a growing number of US hospitals to establish a special
rapid response team that aims to recognize warning signs sooner and
prevent patients from arresting. Holyoke Medical Center established such
a team last year, and Brigham and Women's Hospital will begin testing
the concept on its 14th floor medical unit on Dec. 5.
Howell hopes the team will prevent delays like one he described to the
Beth Israel Deaconess board of directors last month: Doctors admitted an
elderly man to the hospital for gastric bleeding. When his systolic
blood pressure dipped into the 80s, his nurse and an intern gave him
intravenous fluids to push it back up to normal range. His pressure
climbed back into normal range. Over the next eight hours, the patient's
blood pressure kept falling, and they kept pumping in fluids. Low blood
pressure is generally not life threatening until it dips into the 70s or
60s. But they failed to recognize that the subtler decline masked a more
serious underlying problem: massive stomach bleeding. The next morning,
a senior doctor did, and transferred the patient to the ICU, which has
the staffing expertise and equipment to intervene more rapidly. But it
was too late.
''I don't know that we would have saved him," Howell said. ''But it's
absolutely possible."
Now, when a patient's condition worsens in one of six specific ways,
including systolic blood pressure that dips below 90, or when a nurse
has marked concern about a patient, the nurse is required to set into
motion a series of events called a trigger. The nurse pages a special
team -- including a senior nurse, an intern (a first-year doctor), and a
respiratory therapist if it's a breathing problem -- immediately to the
patient's bedside. The intern is required to notify the resident, who is
required to call the attending doctor, or senior physician.
Previously, it was up to nurses to decide whether to call in
reinforcements. And even when they did, interns at times gave
instruction over the phone and did not come see the patient right away.
''At night, when something happens, you ask yourself, 'Is this really
important? Is it really worth bothering a doctor?' " said Rose Segura,
33, a nurse on one of Beth Israel Deaconess general medical floors for
one year. ''This makes it crystal clear there are situations that need
to be addressed. It's a way of reaching up the chain of command to more
experienced people to make sure you're doing the right thing."
Not everyone is convinced.
Australian hospitals were among the first to adopt medical emergency
teams to intervene before cardiac or respiratory arrests, or to transfer
patients to the ICU. One hospital reported in a study last year in the
journal Critical Care Medicine that establishing such a team reduced
mortality among post-surgery patients by 36 percent. Several US
hospitals have reported similar results.
But in a study published in June in the Lancet, Australian researchers
compared 12 hospitals that introduced these teams with 11 hospitals that
did not. Surprisingly, both groups reduced deaths, cardiac arrests, and
unplanned ICU admissions by about one-third. It's possible, Howell and
other doctors said, that the latter group improved care to patients
simply because doctors and nurses knew they were being closely watched
as part of the study.
Because of these results and because of the cost of extra nurses and
doctors to serve on the teams, Brigham and Women's scrapped plans for a
hospital-wide rapid response team this summer and decided to move more
slowly. ''We need to find out is this really going to make a
difference," said Dr. Andy Whittemore, the hospital's chief medical
officer.
Beth Israel Deaconess will study whether there are fewer unexpected
deaths among patients after adopting the team. One issue is whether the
hospital's trigger teams can match the results of the Australian and
other US teams, which generally include doctors or nurses trained in ICU
care.
''A trigger is not about excitement and drama; it's about intervening
before there's drama," Jeanne Quinn, a senior nurse, said Tuesday
morning during break on a unit for post-surgery and trauma patients.
Minutes earlier, Judy Wagoner, a 29-year-old nurse with 2 1/2 years
experience, had activated a trigger when her patient's blood pressure
plunged to 56.
As the senior nurse on the floor, Quinn responded and helped Wagoner
gradually raise Carol Emerson's pressure back into the 100s. The team
ordered an electrocardiogram to rule out underlying heart problems and a
blood transfusion, and kept the patient an extra night. About 80 percent
of the nurses on the floor have less than two years' experience, while
Quinn has 15.

No one knows for sure if early intervention helped Emerson, who was in
the hospital so surgeons could repair broken bones in her left arm,
avoid cardiac arrest. And Wagoner said she would have asked for Quinn's
help even before the new rules.
But doctors believe the key to reducing patient mortality is to
intervene at the first sign of trouble, before the patient ''arrests,"
an emergency involving the heart or lungs -- or both-- shutting down.
According to a 2003 study of 14,720 cardiac arrests in 207 US hospitals,
only 17 percent of patients survived to discharge. Even some top-level
academic medical centers do only slightly better. Brigham and Women's
saves about 24 percent of patients who suffer an arrest, doctors there
said.
Howell said it's so difficult to save these patients because their
bodies already have begun shutting down. Within four to six minutes of a
cardiac arrest, a person's brain cells start dying and the other organs
stop working.
Some of these patients are so sick with underlying heart disease or
other serious illnesses or trauma that they will die no matter what
doctors and nurses do. But in a 2002 British study, researchers found
that 68 percent of 118 cardiac arrests in one hospital could have been
prevented; in almost half the cases, caregivers did not act on a warning
sign that the patient's condition was deteriorating, including low blood
pressure or a deepening coma.
US hospitals that use rapid response teams are reporting better
outcomes. At the University of Pittsburgh Medical Center Presbyterian,
the cardiac arrest rate dropped to 4.5 of every 1,000 patients in 2000
from 6.8 the previous year, and patient mortality fell 30 percent, said
Dr. Michael DeVita, an intensive care physician and associate medical
director of the hospital.
But even at Beth Israel Deaconess, some staff members resisted the shift
in culture -- at least initially. Dr. Inga Lennes and Dr. Amanda
Pressman, both third-year residents, worried the program would create an
avalanche of extra paperwork. ''We didn't want to lose our autonomy,"
Lennes said. ''We didn't want a system where all of these important
decisions are taken out of our hands and moved up the chain of command."
Howell, who supervised them when they were interns, told them the
hospital was going to adopt the teams, so they should find a way to make
it work. The two women decided to survey interns and residents about
their experiences on the teams and hold extra teaching sessions on how
to evaluate and treat patients with potentially dangerous warning signs.
They are starting to see benefits: Now, when nurses call interns and
residents about a problem on the trigger list, the doctors know they
must drop what they're doing and see the patient. ''No one is arguing
anymore," she said. ''It's the policy."

Liz Kowalczyk can be reached at kowalczyk@xxxxxxxxxx
Copyright 2005 Globe Newspaper Company.

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