Paulson Shirley S, Dummett B Alex, Green Julia, Scruth Elizabeth, Reyes Vivian, Escobar Gabriel J
Jt Comm J Qual Patient Saf. 2020 Apr;46(4):207-216. doi: 10.1016/j.jcjq.2020.01.003. Epub 2020 Jan 21.
Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals.
How can one deploy an RRS using an automated EWS at scale?
EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards.
The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.
在重症监护病房（ICU）外病情恶化的成年人死亡率很高。大多数快速反应系统（RRS）采用人工检测流程，快速反应小组（RRT）借此识别有风险的患者。本项目试点使用了基于超大型数据库的自动预警系统（EWS），该系统为快速反应小组提供12小时的预警时间以做出响应。两家医院的试点结果令人鼓舞，因此领导层决定在另外19家医院部署高级警报监测（AAM）项目。
如何大规模部署使用自动预警系统的快速反应系统？
从一线临床医生的医院电子仪表板上移除预警系统显示界面，并在预警系统和快速反应小组之间插入虚拟质量团队（VQT）的注册护士。VQT注册护士远程监控预警系统——发出警报时，他们会进行初步的病历审查并联系医院快速反应小组的注册护士。VQT和快速反应小组的注册护士共同审查病例。然后，快速反应小组的注册护士就临床抢救和/或姑息治疗工作流程与住院医生进行协商。随后，VQT注册护士监控患者病历，确保遵守快速反应系统的实践标准。为实现这一流程，项目团队制定了治理结构、临床工作流程、姑息治疗工作流程和文档标准。
AAM项目目前在北加利福尼亚州的21家凯撒医疗机构医院运行。VQT注册护士每周7天、每天24小时监控预警系统警报。AAM项目每年处理约16000次警报。其实施实现了快速反应小组成员配置、临床抢救工作流程和院内姑息治疗的标准化。
