Rothman Index powerful tool for early detection of subtle patient changes
Gary Bouley, RN, a member of the Rapid Response Team for intensive care units, recently discussed changes in a patient's condition using the Rothman Index. Shown on the Medical Oncology Unit (NP 12) are (l-r): Bouley; Kelsey Lorraine, RN; Alienne Morrione, RN; and Ashley Keyes, RN.
We've heard it a million times: Pictures are worth a thousand words. The Rothman Index, a summary score of a patient's clinical condition that is presented on a graphical display, is now fully integrated into Epic on the York Street Campus. The Index will be available to the Saint Raphael Campus when Epic is implemented there on June 1.
The Rothman Index got its start when a lively 87-year-old woman underwent aortic heart valve replacement in a Florida hospital. She seemed to be recovering nicely but then became very sick very quickly. Staff thought they were observing an 87-year-old recovering after surgery. However, they were missing meaningful signs of deterioration that led to her death a few days later.
Her sons, Michael and Steven Rothman — both of whom had careers in data analysis — dedicated themselves to finding out why her care had failed her. They asked their mother's hospital to allow them to take the electronic medical record data from thousands of anonymous patients and search it for patterns that would reveal changes in a patient's condition that might be so subtle that doctors and nurses could miss them.
Over time, they developed an algorithm based on 26 variables that include vital signs, select lab results and nursing assessments. The Rothman Index (RI) uses the combination of these 26 factors to track a patient's condition and illustrates it graphically.
Now available in Epic, this Rothman Index graph shows a patient’s decline over days. The graph’s background is red, indicating that the patient is at risk for a poor outcome. If the graph’s last data point had been between the red and yellow lines, it would have been in yellow and if it had been above the yellow line, the graph would have been blue.
RI assimilates data already entered into the patient's electronic medical record (EMR). RI data is presented on a graph laid out over three horizontal bars of color which represent the patient's risk for poor outcome: blue represents least risk for poor outcome; yellow indicates moderate risk for poor outcome; and red represents high risk for poor outcome. Data is represented by a dot on a vertical axis, posted hourly as new results are entered into Epic.
"The Rothman Index is a powerful tool for the medical and nursing staff because it helps them see the patient's progress — or lack of progress — over time," said Thomas Balcezak. "RI synthesizes key information into a single data point and presents it visually so clinicians can quickly see a trend that might take longer to deduce from the patient's EMR.
"RI's graphic approach can be particularly helpful to clinicians who have just assumed responsibility for a patient," said Dr. Balcezak. "This data does not replace what clinicians are seeing in the patient but it can help because it puts lots of information together."
Yale-New Haven Hospital first introduced RI to hospitalists and care coordinators working on medical/surgical units and Medical Intensive Care Unit physicians. Nurses throughout York Street tested the index in late 2011 and early 2012. Today, a patient's RI is automatically available to any member of the patient's health team who has access to Epic. The Rothman Index does not track obstetric, psychiatric or pediatric patients, although YNHH is collaborating with other children's hospitals to develop a pediatric RI.
"Yale-New Haven is an early adopter of the Rothman Index because we see its potential to detect a patient's clinically meaningful patterns and help staff respond to deterioration more quickly," explains Joan Rimar, RN, DNSc, manager, Decision Support, Finance. "Clinicians recognize its potential to help them see trends earlier and avoid or minimize poor patient outcomes."
Clinicians can see the patient's stay as well as the patient's trending during previous hospitalizations. Rothman's graphical snapshot points clinicians to a change that indicates that some aspect of the patient's condition needs closer scrutiny. "We have already educated 100 percent of all inpatient adult nurses who use it daily to maintain excellence in the delivery of care and patient outcomes," said Diane Vorio, vice president, Patient Services. "RI provides a visual alert that enables nurses to more easily see emerging patterns and take action that will result in a better outcome for the patient."