Email Updates
A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney. Eight minutes later, the patient was found by a staff member in a bathroom in the radiology department adjacent to the ED. She was on the floor with her shoestrings tied around her neck. She was awake and breathing and was returned to the ED resuscitation room where she was evaluated by the physician. The commentary discusses the importance of timely psychiatric assessment, appropriate use of restraints and direct 1:1 observation, and how ED overcrowding compounds existing challenges in emergency medical care.
A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal. Before the care team could change the tracheostomy, the tracheal cuff burst, and the patient developed hypotension and required 100% inhaled oxygen via the ventilator. The commentary summarizes best practices regarding proper tracheostomy tube choice and sizing to prevent leaks around cuffs, the importance of staff education on airway cuff pressure monitoring, and the role of multidisciplinary tracheostomy teams to optimize tracheostomy care.
Summary
Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response. When indicated, the clinical team implements elements of the evidence-based sepsis bundle.
Piloted in six of the eight health system’s hospitals, the initiative was associated with increased compliance with sepsis bundles and a decrease in hospital mortality in a little over two years. The team found that having a remote monitoring team is a more efficient use of staff and expertise. This benefit became particularly important during the staffing shortages during the COVID-19 pandemic. The process is now an embedded practice in all WellSpan acute care hospitals.
The innovation team believes that the remote nature of the CAT is a key factor to the success of the system. By routing alerts to remote nurses, the clinical team is less susceptible to alert fatigue, and remote clinicians can perform clinical observations and monitoring with fewer distractions and competing priorities. Also important is the adjustable alert algorithm. By using data and feedback, informatics staff can collaborate with clinical teams to adjust the algorithm and alerts, which prevents unnecessary disruptions and allows for greater sensitivity and specificity to signs of sepsis.
Innovation Patient Safety Focus
The innovation focused on reducing mortality by improving response to and management of sepsis.
Evidence Rating
Resources Used and Skills Needed
Important components of the innovation include the following:
- Multidisciplinary teams stationed at each hospital location to oversee implementation
- Standardized EHR alert technology across all locations
- Established, evidenced-based, clinical criteria to inform local protocols on response to sepsis
- Information technology experts to customize and set up the alerts system
- Key performance indicators and timely transparent reporting of unit, team, and individual performance
- Adoption by staff at all levels
- Specialty-trained, experienced remote alerts team
- Communication channels for clinician-remote team collaboration
- Role-based training on the new system for all staff
- Opportunities for cross-functional representatives to build trust, share ideas, and seek help
Use By Other Organizations
The team at WellSpan has received inquiries from approximately 30 organizations seeking information on the innovation.
Developing Organizations
Date First Implemented
This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.
A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits. The stroke team did not order emergent CT angiography and perfusion imaging but recommended routine magnetic resonance imaging with angiography (MRI/MRA) for further evaluation, which showed extensive cerebral infarction in the distribution of an occluded left middle cerebral artery (MCA). Due to the delayed diagnosis of left MCA stroke, it was too late to perform any neurovascular intervention. The commentary highlights the importance of timely use of stroke alert protocols, challenges with CT angiography in early acute ischemic stroke, and the importance of communication and collaboration between ED and neurology teams.
