Hi, everyone. Thank you for joining us this afternoon. We are very excited to share with you a tale of two outcomes using the Rothman Index to impact the patient journey. I’m very excited to introduce two of my
colleagues, Kathy Belk, who is the Chief Data Scientist at Spacelabs Healthcare, and then Dr. Olufunmilayo Ogundele, who we call Dr. O, I wonder why, right? Affectionately! She is the Associate Chief Medical Officer at Mission Health, which is an organization, part of the HCA organization. So they are going to share with you a little bit more about the journeys.

[Dr. Ogundele]

Thank you, Michelle. I’m so excited to be here to share with you how we’re leveraging the Rothman Index to impact our patient journeys. The talk today is really trifold. I’m going to share a particular patient’s journey, and then Kathy is going to provide additional information about the RI. And then I’m going to round out the presentation to talk a little bit more about how we’re using it to impact patients’ journeys at Mission Hospital.

So to start, I’d like to introduce you to Florence. Florence is a 74-year-old grandmother. Florence is anticipated to have a good outcome. But we know that, like many other patients across the country, the journeys can diverge for patients. Getting home is what matters most. So let’s explore the first journey for Florence. From day one, Florence developed some confusion and agitation. So when you look at her vital signs, maybe a little hypertension, but nothing really alarming. Overall, largely unchanged. Well, by post-op day two, her pulse is thready, her skin is a little mottled, and she’s developed some labored breathing. Now post-op day three, she’s now tachycardic. She’s tachypneic. And when you look at the last set of vital signs, there’s actually a 65 drop in her systolic, so some relative hypotension. And at this time, given how sick that she is, the care team did transfer her to the ICU. But unfortunately, she’d already developed multi-organ failure and had subsequent death.

But her journey really didn’t have to be that way, right? Because what if we had additional information that could have changed Florence’s journey? So let’s see what that journey looks like. So again, Florence has the surgery. Things are looking good. Again, post-op day one, she’s confused. She’s agitated. But this time, we have information from the Rothman Index. We can see clearly that she’s now in the medium warning lane for the RI. So the care team now, they’re going to huddle. They’re going to review her trends, which Kathy is going to discuss a little bit more about. And her nursing assessment frequency has now increased. So again, post-op day two, she has those changes. She’s thready pulse, mottled skin, labored breathing. And now we can clearly see that she’s progressed now from first medium, now to a high RI, and then a very high warning. So now the high and high warning protocol is now initiated. So the care team now, they’re going to do more diagnostics.

So they get a CBC. They’re very much concerned for sepsis. So now they’re going to start IV fluids, antibiotics, and she’s going to be transferred proactively to the ICU. And because of this proactive escalation, now Florence gets to go to rehab and eventually goes home, where she’s reunited with her family. The one thing I actually want to mention with the RI is the importance of nurse assessments to how the RI is generated. We can clearly see that when Florence’s vital signs were relatively unchanged, and she was having the confusion, and she was having the agitation, they weren’t really vital signs that would cause us to, let’s say if we were in the cafeteria, we would drop our sandwiches and we would run, right? However, the RI was already indicating that something was very wrong with Florence. So her neurologic assessments, she failed those. She fell out of bed, so safety. Her psych assessments, she failed those. And those subtle things that the static vital signs that we look at that they don’t pick up, these are things that the RI can harness out of the notes of our nurses to actually indicate that something’s very wrong. So the value of the RI to you as a clinician are really the patients that you should be worried about, but you’re not worried about. So I’m going to turn it over to Kathy to talk a little bit more about the Rothman Index.

[Kathy Belk]

Thanks, Dr. Ogundele. I’d like to start a little bit with the journey of the Rothman Index, because it began very similar to the first patient journey that we just reviewed. So the woman that you see here is Florence Rothman. She went to a very well-respected hospital, was going for a valve replacement, expected to do very well, had surgery, and post-op, she started to recover. However, over the coming days, she got progressively worse, just a little bit every day, nothing that was very alarming. She was discharged, and then she was actually rushed back to the hospital and subsequently expired. The two men that you see here are her two sons. They’re both scientists, and they had watched all this data in the EMR as their mom was in the hospital room. And so they asked the facility, you have all this information, why did you not see that Mom was getting worse? Why did you discharge her? And the response was that even though there was a lot of information, it wasn’t digestible. It wasn’t something that was easily actionable. You had to dig. There really wasn’t time to go in and dig through every element of the EMR to understand what was going on.

And so they developed the Rothman Index to really be that guide, to be able to give insight to clinicians that gave them actionable information that summarized all that data that was in the EMR. So I mentioned the Rothman Index is an aggregate score of patient physiology, it’s an aggregate score of patient condition. It is comprised of the vitals, the labs, as well as those clinical nursing assessments that Dr. Ogundele spoke about. Sometimes those are very subtle changes that are leading indicators that something’s going on with the patient. You know, did they stop eating? Did they become confused? Does their breath suddenly become wheezy? Do they have retractions? And so that is the information that’s aggregated into a score. And we get that information from the EMR. So it’s not like a nurse has to go in, do additional documentation, the physician doesn’t have to do additional documentation. It leverages data that already exists and pulls that insight to the surface.

I think another thing that’s really important to point out, you know… you’re all here about performance improvement and about quality improvement. A score like this doesn’t do any good unless you implement it into the workflow, unless somebody sees that information and acts upon it. And so one of the things that we like to do is figure out what your workflow looks like, what does your use case look like, and then customize how you get that information back into your workflow. There’s several different options you can see here. One is a patient level view. You can go into a UI software, you can launch it straight from the EMR, see all the detail. You can also integrate it back into the EMR through flow sheets. So if you have a patient list, if you have a transfer report, a piece of information you’re already using, it’s a document that’s already part of your workflow, can we incorporate this trend, this score into that document so that you have that information at your fingertips?

We also have a mobile platform. So you think a lot of times our rapid response teams, the clinical nurse specialist, they’re out on the floor, they’re moving around, they don’t often have access to a laptop. So you can access it through a mobile platform very easily, see the same information, and do something like a proactive rounding.

And then we also have at the top here, you can see all the little graphs, that is a surveillance type screen. So you can actually see all the patients on a unit if you’re a charge nurse, or if you’re looking at a command center, all the patients in your facility and see who is most concerning and how do you prioritize maybe bed transfers, or how do you prioritize going to do rounding or other things. So this is an example of a graph, and each of those little dots that you see there is new information has come into the system and a new score is generated.

And the beauty of it is you can see the trajectory of the patient. So is that patient getting worse? Is that patient getting better? Are they remaining the same? And you can see here, as we saw in the example, there’s three levels of warning. The yellow is a medium warning. So maybe you want to have some kind of protocol. Maybe you just want to increase nursing assessment frequency if a medium warning occurs. Let’s get some more eyes on that patient. Maybe you have a different protocol when they hit a high, maybe that’s a care team huddle. But we can wrap around your process, what happens when these triggers occur.

The other thing that’s very important is on the right, you can see all the detail of the 26 elements that make up the Rothman Index. So as you’re communicating, as you’re trying to say what’s going on with this patient, what’s happening, is their score decreasing, increasing, those are the drivers. And it tells you, okay, this patient, you know, suddenly has mottled skin. This patient, you know, their blood pressure has gone from, you know, this number to this number. All the information that’s driving the change in the patient is available in that drill down so that it can become actionable information between the two clinicians.

So now I’m going to turn it back over to Dr. Ogundele, and she can talk a little bit about how it’s being used at Mission.

[Dr. Ogundele]

Thank you. Just going to get a little granular about how we’re using the RI at Mission Hospital. There are a number of ways that we actually do this. So the first way is with our bed management. So our house supes, they work with our logistics center, and they’re able to help us to place the right patient in the right bed at the right time. It’s very important. We know that, you know, placing the patients initially in the right place, we know that patients who go to the wrong place and end up in the ICU, they do worse. So it’s very important to make sure that when they come into our hospitals, that we’re placing them in the appropriate location.

So once our house supes, and, you know, Mission is, we have over 800 beds. So as you can imagine, at any given time, we have multiple patients who need to go to med surge, who need to go to step down, and who need to go to the ICU. The question is always, who are we going to give bed to first? They’re all sick. They all need to be in the hospital. And I think that’s where the value of the RI comes in. Because whereas you may have maybe five patients who seemingly seem like they all are at the same level of acuity, the RIs are very much different. And the RI then really helps you pick the patient with the lowest RI or with the downtrend to prioritize the bed for that patient. So now once they’re in the walls of our hospital, another way that we’re able to best manage our beds are our patients who are decompensating.

And what that looks like is really identifying those patients and determining whether we now need to move them to a higher level of care. And once they’ve completed their care at the higher level of care, other decisions are, you know, can they go to the floor? Is the RI reassuring that if we sent this patient to the floor, they’re not going to bounce back to our ICU our step down? Now resource utilization is also another valuable place where we leverage the RI. We all know about nursing shortage. So the surveillance view that Kathy discussed, when a charge nurse comes into the unit, we have new nurses or nurses at various levels of experience. So do we really want to give our new nurse, you know, seven patients who are all flagging in the medium warning? Or do we, let’s say, give our new nurse maybe five patients that aren’t flagging at all and maybe two patients that are in the medium warning lane? So it really helps our charge nurses to make decisions on how they allocate patients to specific nurses. It would leverage this as with our proactive surveillance.

And this really is in the wheelhouse of our rapid response team. So our rapid response team, they actually have RI mobile. So on their mobile devices, they’re able to see the house. They sort of know which patients, not only what their RI is, but more importantly, what the trends have been, right? Being able to pick up the patients who’ve been downtrending, let’s say, in the last six hours, last 12 hours, or over the last 24 hours, putting them on that list of focus. And what that really does, it really triggers proactive rounding. So what they do is they really wrap around resources to that bedside nurse. They’re able to have these conversations with our providers. Do we need to do extra tests? Or do we simply need to move this patient to the ICU? And in some cases, the triggers are also, do we need palliative to weigh in on this patient? Do we need to have more discussions? We all know that in multidisciplinary rounds, there’s a lot of information that’s exchanged. And the RI for me, admission, and I think for our care team, becomes important because it’s a common language. Describe how a patient is doing. I can try to go through the many pages of the EMR, but the RI really summarizes, right, for the care team, how that patient is responding to therapy.

We know that there’s a big difference, let’s say, if a patient’s RI is 65. It really triggers an entirely different conversation. And I think another way we’ve leveraged the RI is with our families. Nowhere is it ever more true that a picture is worth a thousand words than when you show a family member the RI, and you explain the basics to them on what the numbers mean. And our patients and their families really engage, and they really come to expect when they show up on rounds, that we’re going to show that to them. And very often, family members, they interpret it for themselves. They’ll even say on rounds, well, I mean, it’s obvious mom and dad, they’re not doing well. It continues to go down. What are we really doing here?

So I think for our families, it really becomes important that we have a common language, that they have the same understanding that the care team has. Two weeks ago, we had a patient that had been there for a while, and we were all, you know, really happy for the patient, and we want to send the patient home. Unfortunately, the RI was downtrending, and when they did the drill down, you know, the patient was tachycardic, and the care team simply said, this is not a patient that we feel comfortable sending home. We need to keep that patient.

We need to do more diagnostics to figure out what’s really going on with this patient. So making sure that, you know, when patients are within the walls of our hospital, that we’re putting them in the right bed. It’s also important that when they leave the walls of our hospital, that we’re putting them in the appropriate post-acute care setting.

So to summarize, the RI is used, you know, by a multidisciplinary team. It’s used to support decisions, so whether that decision is that we’re going to put a patient in a higher level of care, whether the decision is, is this safe to downgrade this patient, or simply, is this patient safe to go home from the hospital?

I think the RI is a partner with clinicians. It does not replace your clinical judgment. It’s really an augmented insight, right? It’s the patients that you should be worried about, but you don’t know that you should be worried about them. It’s another set of eyes that tells you that something is wrong, and that patient really, really needs some attention. By helping to make these care decisions, the RI really ensures that we always put the right patient in the right bed at the right time. So this is a paper that we’ve just submitted. It’s actually in pre-publication, and it really looks at our ICU readmission, how we’re leveraging the RI. We know that readmissions to the ICU is associated with mortalities, as well as increased length of stay. So this is a paper that describes that, and hopefully, if you’re interested, you will check out the paper.

So in closing, I’d just like to say that I echo with Kathleen the story that she recounted in the beginning, and I want to echo Michael Rothman’s definition of success, right? So he defines success as if we could save one other person. Well, we no longer have to say if, because since the original Florence who inspired this story, many hospitals across the country, including Mission Hospital, can now say, and we saved one other person. So the road diverges, and it’s going to continue to diverge for our patients. And I think the question is, which road would you want your patient to travel? Thank you very much.

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A Tale of Two Journeys Podcast
Monday, March 25, 2024 (length: 17 minutes 10 seconds)