Published in the June 2011 issue of Today’s Hospitalist
AT ONE OF SOUTHERN CALIFORNIA’S busiest hospitals, the rapid response team doesn’t just come running when called by nurses or doctors. It also responds to calls from patients or family members who feel that an emergency isn’t being recognized.
St. Joseph Hospital in Orange, Calif., created "Condition H" (for "Help") as a last resort for patients and families. The program has averted at least one clinical emergency and resolved dozens of communication and coordination snafus and misunderstandings.
Since the program was launched in March 2008, there have been 70 Condition H calls, according to Soudi Bogert, RN, CCRN, the hospital’s critical care outcomes coordinator who co-chairs the 525-bed hospital’s medical emergency team. (That’s what St. Joseph calls its rapid response team.)
In addition to giving patients a well-received outlet for their concerns, Condition H has helped shine a light on those aspects of hospital care that need more attention “specifically, communication among providers, care coordination and pain management.
A last resort
"Our biggest problem occurs when more than one physician is seeing the patient, mostly consulting physicians," Ms. Bogert says. "Patients get conflicting advice about the plan of care, and they have no idea what is going on. The doctors are talking to the patient, but the doctors aren’t talking to each other."
The second most common group of Condition H calls comes from patients who feel their pain isn’t being adequately treated. A third group of calls relates to unexplained delays in care, like a pending test that isn’t taking place or delays in discharge.
What hasn’t happened in the three years Condition H has been operating is what many skeptics originally feared: that the system would be overwhelmed by non-emergency calls from complaining patients and hard- to-please families. "A lot of people were worried that we would get calls all the time," says Ms. Bogert, who wrote about pilot testing Condition H in the July/August 2010 issue of MED-SURG Nursing. "But it’s like 911: People don’t abuse it. They use it as a last resort."
Different types of emergencies
Since Condition H was launched, Ms. Bogert adds, there have been only one or two calls that ended up being not a true emergency. In fact, she says, underuse has been a much bigger problem. Her department is always trying new ways to get the word out about Condition H to families and patients.
In addition to hallway posters, notices in every admission packet and announcements on the hospital’s TV channel, the initiative’s organizers recently created a laminated flyer about Condition H “in Spanish and English “and put one in each patient room.
But patients and families aren’t the only ones who need regular education about the program. Ms. Bogert says that doctors, nurses and other providers have to learn that their concept of a crisis or emergency may not be the same as a patient’s. Nurses need to be reassured, for instance, that a patient’s call is not a direct criticism of them.
"Working in health care, our emergency factor is really high because we see so much," says Ms. Bogert. She reminds staff to respect how patients and families interpret the program. "You have to put yourselves in their shoes. In their eyes, it was an emergency."
While Condition H team members as well as managers used to think some calls weren’t warranted, "in consistent debriefing, we discuss each event," Ms. Bogert says. "The team has come to realize that each event is unique, as is each caller."
A range of calls
The first Condition H call that came through set the tone for the program. The family of a patient about to be discharged to a skilled nursing facility dialed 66 (the "911" of Condition H), concerned because of a bad experience with that facility in the past. The alternative was to have their mother stay in the hospital one more day to give them time to arrange home care.
"They felt they had an emergency and that no one was listening," Ms. Bogert says.
The Condition H team was able to get case management involved and file an appeal with Medicare. The family decided to risk having to pay for an extra day themselves if the Medicare appeal failed. "They ended up feeling like they had a voice," Ms. Bogert explains.
Then there was the Condition H call from a son explaining that "something is not right" with his mother. After the team investigated, it found that the patient was hypothermic and transferred her to the ICU, where she suffered a non-fatal cardiac arrest.
Who’s on the team
At St. Joseph, the medical emergency team is nurse-led and operated and consists of a critical care nurse and respiratory therapist. (An intensivist is available for immediate consultation.) The Condition H team, by comparison, is made up of that medical emergency team nurse, a respiratory therapist, a consulting intensivist (if needed), the house supervising nurse and the charge nurse from the floor where the call originated. While hospitalists don’t directly participate in the medical emergency team program, they do collaborate with protocols and order sets.
When a patient dials "66," the hospital operator follows a simple decision-tree to make sure the call wasn’t made by mistake. (Patients have used the number to report a remote control that wasn’t working or a missing dinner tray.) The operator then pages the medical emergency team, house supervising nurse and floor charge nurse, who respond within minutes.
If the emergency is clinical, it will be treated as a medical emergency team call. If it relates instead to discharge planning, a delay in care, confusion with the care plan or any other type of emergency, the house supervising nurse takes the lead. A patient service representative will follow up with a visit within 24 hours. A report on every call, without patient identifiers, goes to the units and the medical staff quality enhancement committee, just like regular rapid response calls.
Ms. Bogert says she is constantly being asked about Condition H by other hospitals that are flirting with the idea of a patient-activated rapid response team. She recommends that hospitals just go ahead and take the plunge. The lesson learned at St. Joseph, she adds, is that patients overwhelmingly appreciate having the ability to call.
The only prerequisite to making Condition H work, Ms. Bogert points out, is that hospitals have a rapid response team up and running. Then, Condition H can be easily layered on, becoming just one more spin-off team that hospitals are setting up. Other examples at St. Joseph include a behavioral emergency response team for psychiatric emergencies, postpartum/ante-partum resource teams for OB-GYN patients, and an ED response team that responds to visitor and staff emergencies.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.