Opinion | How to Quantify a Nurse=?UTF-8?Q?=E2=80=99s_=E2=80=98Gut_Feelings=E2=80=99_?=- The New York Times

Tom Benzoni benzonit at GMAIL.COM
Fri Aug 10 20:25:15 UTC 2018


These are all interesting stories and they have one major cognitive error
that I haven't seen called out.
I'll leave the contest open for a few hours.
tom benznoi

On Fri, Aug 10, 2018 at 1:03 PM Rory Jaffe <rjaffe at chpso.org> wrote:

> There are others that have also come up with automating the process of
> identifying deterioration early and flagging it for action.
>
>
>
> My biggest problem with the Rothman index is that it is proprietary. That
> impedes progress, spread, and improvement.
>
> *From:* Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
> *Sent:* Friday, August 10, 2018 6:56 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a
> Nurse’s ‘Gut Feelings’ - The New York Times
>
>
>
> I’ve never heard of the Rothman index, but if it can help identify a
> deteriorating patient I’m all for it.  Even better, nurses need to be
> recognized as essential members of the diagnostic team.  In this case, the
> nurse’s ‘gut sense’ that something was wrong was the lost key to making a
> more timely diagnosis of cardiac tamponade.  The #1 recommendation in the
> National Academy report on “Improving Diagnosis in Healthcare” was to
> improve teamwork in the diagnostic process, and this means, foremost, *the
> nurse* and *the patient*.  I’m guessing Mrs Rothman’s sons had the same
> gut sense as the nurse in this case.
>
>
>
> I’m very proud of SIDM’s new special interest group focusing on nurse
> engagement in diagnosis, headed up by Becky Jones at the Pennsylvania PSA
> and Kelly Gleason at Hopkins.  Members of this group have recently authored
> papers
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.ncbi.nlm.nih.gov_pubmed_29536939&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=yTpfkJ7mUKof-oQKg2Fb6rSWrDsyedpoVExNRXzjDWc&s=Nbx-Rra_wjWVUb4SZun_9O9snQxy1UWlpzNthsZthEg&e=>
> on the need to increase nursing engagement.  We are also in the process of
> recommending a new curriculum on diagnosis and diagnostic error that would
> be part of the training of every healthcare professional, including
> nurses.
>
>
>
> Of the many recommendations on how to improve diagnosis, involving nurses
> (and patients) offers a clear path to fewer errors.
>
>
>
> Mark
>
>
>
> Mark L Graber MD FACP
>
> President, SIDM
>
> Senior Fellow, RTI International
>
> Professor Emeritus, Stony Brook University
>
>
>
>
>
>
>
>
>
> *From: *David L Meyers <dm0015 at COMCAST.NET>
> *Reply-To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>,
> David Meyers <dm0015 at comcast.net>
> *Date: *Thursday, August 9, 2018 at 11:06 PM
> *To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject: *[IMPROVEDX] Opinion | How to Quantify a Nurse’s ‘Gut Feelings’
> - The New York Times
>
>
>
> Food for thought...
>
>
>
> https://www.nytimes.com/2018/08/09/opinion/sunday/nurses-gut-feelings-rothman.html?WT.nav=opinion-c-col-right-region&action=click&clickSource=story-heading&module=opinion-c-col-right-region&pgtype=Homepage&region=opinion-c-col-right-region
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.nytimes.com_2018_08_09_opinion_sunday_nurses-2Dgut-2Dfeelings-2Drothman.html-3FWT.nav-3Dopinion-2Dc-2Dcol-2Dright-2Dregion-26action-3Dclick-26clickSource-3Dstory-2Dheading-26module-3Dopinion-2Dc-2Dcol-2Dright-2Dregion-26pgtype-3DHomepage-26region-3Dopinion-2Dc-2Dcol-2Dright-2Dregion&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=yTpfkJ7mUKof-oQKg2Fb6rSWrDsyedpoVExNRXzjDWc&s=_WD7VjLIQl4tW9law_gj-YcP7kEh-TT0rIPPRlfVQmA&e=>
> How to Quantify a Nurse’s ‘Gut Feelings’ I had a nagging sense that
> something was wrong, but I couldn’t articulate it.
>
> Aug. 9, 2018
>
> *By Theresa Brown*
>
> *Ms. Brown is a hospice nurse.*
>
> [image:
> https://static01.nyt.com/images/2018/08/12/opinion/sunday/12brown/merlin_142164237_8a4ba07f-7ed1-4885-83f2-90a77d624e1d-articleLarge.jpg?quality=75&auto=webp&disable=upscale]
>
> Wenting Li
>
> At the start of my shift, at 7 a.m., my patient, newly admitted a few days
> before for a blood cancer, was talking and acting normally. By the end of
> my shift, 12 hours later, she had grown confused and her speech was
> garbled. A CT scan revealed bleeding in her brain. She was sent to
> intensive care and died the next day.
>
> This was years ago, but the case still haunts me. I believe that moving
> faster on her treatment might have prevented her sharp decline. But the
> medical team didn’t share my sense of urgency, and no obvious red flags
> signaled a coming emergency. Without a worrisome clinical value or test
> result to point to, my concern alone wasn’t persuasive.
>
> Every nurse likely knows the feeling. The patient’s vital signs are just a
> little off, she seems not quite herself, her breathing is slightly more
> labored. But on paper she looks stable, so it’s hard to get a doctor to
> listen, much less act.
>
> In such situations nurses invoke “gut feelings,” but they actually aren’t
> feelings at all — they are agglomerations of observations and experiences
> that over time have turned into finely tuned clinical judgment. The idea is
> that working at the bedside has honed nurses’ perceptions to be especially
> alert to brewing trouble.
>
> These reactions and observations typically aren’t given the clinical
> weight of test results and lab values. Similarly, a large part of every
> nursing shift is spent on the computer documenting how patients are doing,
> but the content of these notes is more often than not ignored, particularly
> by physicians.
>
> It doesn’t have to be this way, and it may not be for much longer. The
> change began in 2003, when an 87-year-old woman named Florence Rothman was
> hospitalized for a heart-valve replacement. She was in good health and
> initially did well, but experienced a slow, unnoticed deterioration in the
> hospital. She eventually received treatment for her symptoms, but no one
> investigated the cause. However, she improved and was sent home.
>
> Four days later Ms. Rothman was seen by a home health nurse during an
> episode of severe breathlessness. When it happened again the same day, her
> family called 911, but it was too late: Her heart stopped in the emergency
> room, crushed by fluid surrounding it.
>
> Ms. Rothman’s sons — Michael, an engineer, and Steven, a data scientist —
> wondered if their mother’s death could have been avoided, had there been a
> better way to track her signs of distress. Doctors later determined that
> she had developed a condition called cardiac tamponade, and it probably
> started during that first deterioration in the hospital. If her overall
> condition had been thoroughly examined at that point, the tamponade likely
> could have been detected and treated.
>
> Together the Rothman brothers came up with the Rothman Index
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__perahealth.com&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=yTpfkJ7mUKof-oQKg2Fb6rSWrDsyedpoVExNRXzjDWc&s=wZuVMsW9urXfqab-7lh48xJ-H6MLt1l6KD5IwFWmneQ&e=>,
> a commercial product that uses data from standard electronic health records
> — including lab values, vital signs, cardiac rhythms and key aspects of
> nursing assessments — to monitor hospital patients. It tracks their status
> as a graph that falls into a blue, yellow or red zone, based on whether
> they are at low, medium or high risk of an acute event. Michael Rothman
> said cartoons about hospitals that show a chart with a zigzag line appended
> to the foot of each patients’ bed reflect the visual power of the Rothman
> Index.
>
> The goal is to identify those patients who might look stable but are in
> fact fragile; applied correctly, it allows medical teams to intervene well
> before a crisis hits. This saves lives, and money. I have seen the Rothman
> Index in action at the Yale New Haven Health System, where special SWAT
> team nurses use it to coordinate care for the sickest patients.
>
> The Rothman Index empirically validates nurses’ gut feelings by showing
> that nursing assessments — what nurses see and document when they “lay
> eyeballs” on patients — offer crucial information about patient stability.
> It validates what nurses have known all along: that well-honed clinical
> instincts matter.
>
> Part of why I still feel haunted by my patient who suddenly took a turn
> for the worse and then died is because of that nagging sense I had, early
> on, that something was wrong. Her disease put her at risk for spontaneous
> bleeding, but at the start of her third day in the hospital a treatment
> plan still wasn’t in place. My gut told me we were moving too slowly, and I
> was able to push here and there. But there was nothing I could articulate
> as a sign of impending calamity.
>
> I don’t have access to that patient’s records, so I can’t go back and
> chart her Rothman Index. But I can promise myself that in the future, I
> will take any sense of urgency very seriously, document my concern and
> speak up. There’s now solid evidence that when a nurse says she’s got a bad
> feeling about a patient, the entire care team needs to listen.
>
> *Theresa Brown, a hospice nurse, is the author of “The Shift: One Nurse,
> Twelve Hours, Four Patients’ Lives.”*
>
>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
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>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
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>
>
> To unsubscribe from IMPROVEDX: click the following link:
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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