[No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a Nurse=?utf-8?Q?=E2=80=99s_=E2=80=98Gut_Feelings=E2=80=99_?=- The New York Times

Rory Jaffe rjaffe at CHPSO.ORG
Sat Aug 11 00:10:17 UTC 2018


Now we get to: what does the human do with the computer (or paper algorithm)?

The answer is, it varies. Questions to ask:

  1.  What is the sensitivity/specificity?
  2.  In this population, what is the false positive/false negative rate? (Applying a good algorithm to a low-risk population elevates the false positive rate a great deal).
  3.  What is the cost (human and financial) of treating false positives even though they don’t need the treatment?
  4.  What is the cost (ditto) of not treating the false negatives even thought they need the treatment?
  5.  I’m sure there’s more questions, but this is a start.

With sepsis, delays in treatment kill people. Treating people who don’t need it has issues, particularly with antibiotic stewardship. But, on balance, it appears appropriate to weigh the criteria towards overtreatment than undertreatment. Yes, studies need to be done to help us maintain the right balance between aggressiveness and false positives and to optimize outcomes.

Waiting to get the right diagnosis, in the case of sepsis, appears to be more harmful than jumping on a possible case before a definitive diagnosis can be made.
One of the things we’ve got to be better at is stopping sepsis treatment once it becomes clear the patient, while initially meeting screening criteria, doesn’t have it. Thus the interest in C-reactive peptide and other possible means of improving rule-outs of sepsis.

By the way, this echoes the stuff I was talking about earlier about peripartum hemorrhage. In an emergency (possible sepsis, possible peripartum hemorrhage), follow a well-designed algorithm that has as its goal optimal care for the population and defer diagnosis until the act of making a diagnosis will cause appropriate branching within or out of the algorithm that would provide better evidence-based care than the algorithm would—and be humble when making a diagnosis, knowing we’re far from perfect at doing so.  We have extremely strong evidence that following that hemorrhage algorithm saves lives (just compare California to the rest of the US). I’m sure there’s some overtreatment spurred by the algorithm, but so what?

To be provocative, I believe that, in emergencies, the role of obtaining a proper diagnosis is overrated (although on occasion quite important), and attempting to obtain a diagnosis and act upon it may even be deleterious. What is more important is to have a carefully constructed playbook, like airline pilots do, that guides us properly through the emergency, and that calls out when cognitive work (diagnosis) is beneficial and when IT IS NOT.

From: Tom Benzoni <benzonit at gmail.com>
Sent: Friday, August 10, 2018 4:22 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org>; Rory Jaffe <rjaffe at chpso.org>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a Nurse’s ‘Gut Feelings’ - The New York Times

Picking up the 2% gauntlet, what is the posit on false (+)?
You can't improve sensitivity without sacrificing specificity.
And you can't toss this part back on the displaced humans. They're ejected.
This is advised by our current sepsis screen. Everyone with abnormal vitals is (+). Truly septic patients with temporary normalization of their vitals screen (-) and I'm supposed to sorry this out?!
There is tremendous pushback on studying this phenomenon. The apps beg for review.
Tom

On Fri, Aug 10, 2018, 17:41 Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>> wrote:
I want both. The algorithm is there to assist the human in pattern detection.

In the framework of high reliability, what we’re trying to do with surveillance systems is improve situational awareness. Humans have limited ability to assess complex trends. Systems that make the situational status more obvious make it easier to maintain situational awareness.

Even experience skilled nurses will miss things. That’s the nature of human fallibility. Responding to clinical deterioration is very important, and I don’t think we should tolerate missing 2% of the patients who deteriorate. Yet, if we rely on people, our most talented folks will probably have at least that rate of misses. Anything that requires higher success rates than about 98% or so requires system support. And that 98% figure is for simple things, like giving the drug to the correct patient. For something as complex as detection of deterioration, I suspect that the failure rate for talented folks without system support is much greater than 2%.

I know you were being intentionally provocative in your comments, but this is exactly the argument that you will see with computer-assisted diagnosis. Those algorithms are dumb too.

The problem isn’t that the algorithm is dumb, the problem is that we’re not sophisticated enough about how we think about automation and integrating them into our own decision-making. There are plenty of examples where people rely too much on automation, thinking that since it’s automated it’s correct. See the Asiana crash in San Francisco; the nurse who gives the wrong prn medication to the wrong patient because he thought that a successful bar code scan ensured the five rights; etc.
From: Mark Graber <Mark.Graber at Improvediagnosis.org<mailto:Mark.Graber at Improvediagnosis.org>>
Sent: Friday, August 10, 2018 2:54 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a Nurse’s ‘Gut Feelings’ - The New York Times

Rory – So say you are hospitalized for some major illness and you’re given the choice of being watched by Rothman’s algorithm, or an experienced, engaged nurse.  You’re picking Rothman’s algorithm?  Its seems like a choice between a reliable but ‘dumb’ algorithm, vs someone who knows and understands clinical medicine in a thousand different ways.
Mark

From: Rory Jaffe <rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Rory Jaffe <rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>>
Date: Friday, August 10, 2018 at 2:32 PM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a Nurse’s ‘Gut Feelings’ - The New York Times

Intuition is important, but relying upon it for things that happen frequently (such as decompensation) is not reliable. That’s why decision support (such as a decompensation indicator based off the EHR) is important. We should reduce the need for routine intuition but encourage its use for alerting us to unexpected issues. That’s part of what high reliability is all about.


From: Karen Cosby <kcosby40 at GMAIL.COM<mailto:kcosby40 at GMAIL.COM>>
Sent: Friday, August 10, 2018 8:24 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [No SPF Record] Re: [IMPROVEDX] Opinion | How to Quantify a Nurse’s ‘Gut Feelings’ - The New York Times

What makes this harder is that clinicians know that intuition is important, but it is often vague and nonspecific.  "I knew something was wrong" but what could/should you have done  about it?  I have experienced this sort of thing many times, and even with increased vigilance been left with an Ah-ha moment later when it suddenly makes sense only after something new surfaces to inform.  Don't know if you could arrive at that moment sooner.  You can worry about that nagging feeling, but it doesn't do much good if you don't know what to do about it. Unfortunately if you just stab at possibilities, you may still go down the wrong path.

On Fri, Aug 10, 2018 at 8:55 AM, Mark Graber <Mark.Graber at improvediagnosis.org<mailto:Mark.Graber at improvediagnosis.org>> wrote:
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=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=OmStsi1bCRCKRl79XXzlU0xOKvUpRyqcZwTD63fuKjY&s=6Krkt7LEELEMMetPCiBaaCB35J92rjMbKud3WBBwUu0&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
[cid:image002.jpg at 01D4309B.C72DAAF0]



From: David L Meyers <dm0015 at COMCAST.NET<mailto:dm0015 at COMCAST.NET>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, David Meyers <dm0015 at comcast.net<mailto:dm0015 at comcast.net>>
Date: Thursday, August 9, 2018 at 11:06 PM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=OmStsi1bCRCKRl79XXzlU0xOKvUpRyqcZwTD63fuKjY&s=MNqwRXZTrTHNhlI_OcWbpWDaGAcdpUZOTQV4MqwjTWg&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.
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=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=OmStsi1bCRCKRl79XXzlU0xOKvUpRyqcZwTD63fuKjY&s=owcULJbEbr8rZXLkD9wRMTGmxceQuGNN0_OWumbXOkM&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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