Improving care quality through nurse-to-nurse consults and early warning system technology : Nursing Management

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Improving care quality through nurse-to-nurse consults and early warning system technology

Goellner, Yvonne MSN, RN; Tipton, Eydie MSN, RN, CCRN-K, CNML; Verzino, Tammie BSN, RN; Weigand, Laura BSN, RN, CCRN, TNS

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Nursing Management (Springhouse) 53(1):p 28-33, January 2022. | DOI: 10.1097/01.NUMA.0000795580.57332.fa
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In Brief


Rapid response teams (RRTs) in hospitals emerged over 15 years ago in response to the Institute for Healthcare Improvement's “100,000 Lives” and “5 Million Lives” campaigns.1 Since their introduction, best practices surrounding RRTs have been ever evolving. The most recent literature promotes the use of an early warning system for detection of declining patient condition and initiation of proactive RRT rounding to promote appropriate escalation of care and decrease the incidence of failure to rescue cases.2

A pilot project was implemented at a 340-bed city hospital in West Central Illinois to improve the quality of nursing care and reduce the number of code blue emergencies outside the ICU through early recognition of clinical deterioration and proactive rounding utilizing a new critical care consult nurse role, the Rothman Index early warning scoring tool, and an upgraded electronic display component of the tool.

Literature review

Early warning tools are frequently used to assist nurses in early identification and clinical correlation of patients' physiologic changes.3,4 The Rothman Index early warning system is a useful predictive tool for 24-hour mortality, discharge disposition, and 30-day readmission through incorporating information derived from the nursing assessment and predetermined physiologic goals of a patient's health status.3 This tool is sensitive to subtle changes in patient condition before any significant physiologic manifestations.3

The Rothman Index produces a continually updated patient condition score independent of specific events, diseases, procedures, or environments. It also incorporates sufficient clinical variables to provide sensitivity to patient risk across the health continuum of unimpaired health to gravely ill.5 The index can be applied in the acute care setting to monitor for changes in patient condition based on variables in nursing assessment documentation and lab values. (See Table 1.) Integration of lab data in conjunction with physiologic variables can increase early RRT activation and lead to fewer subsequent RRT activations.6,7

Table 1: - Rothman Index early warning system input variables5
Vital signs Nursing assessments Lab tests Cardiac rhythm
  1. Temperature

  2. Diastolic BP

  3. Systolic BP

  4. Pulse oximetry

  5. Respiratory rate

  6. Heart rate

  1. Cardiac

  2. Respiratory

  3. Gastrointestinal

  4. Genitourinary

  5. Neurologic

  6. Skin

  7. Safety

  8. Braden score

  9. Peripheral vascular

  10. Food/nutrition

  11. Psychosocial

  12. Musculoskeletal

  1. Creatinine

  2. Sodium

  3. Chloride

  4. Potassium

  5. Blood urea nitrogen

  6. White blood cell count

  7. Hemoglobin

  1. Asystole

  2. Sinus rhythm

  3. Sinus bradycardia

  4. Sinus tachycardia

  5. Atrial fibrillation

  6. Atrial flutter

  7. Heart block

  8. Junctional rhythm

  9. Paced

  10. Ventricular fibrillation

  11. Ventricular tachycardia

Early warning systems that generate data from the electronic medical record (EMR) can provide nurses with real-time updates on patient condition.7 When nurses can visualize patient changes, it promotes critical thinking and improves the timeliness of RRT activation.8 Because RRTs were developed for assessment and early intervention of clinically deteriorating patients, a similar team approach to using an early warning scoring tool can help nurses detect subtle changes in their patients' condition.9,10

Multiple studies support that critical care nurses who work as a multidisciplinary team to consult on patients before a clinical deterioration can positively impact outcomes, such as decreasing discharge delays and unplanned ICU admissions/readmissions, preventing adverse events, and reducing mortality on general hospital units.2,10 The proactive approach to RRTs, combined with an early warning system, has been shown to significantly impact hospital length of stay and unplanned ICU transfers.11


In September 2017, the hospital implemented a new technology system to streamline care in the ED and hospital-wide. This new system changed the roles and responsibilities of the charge nurses and care managers by combining both jobs into one role. A multidisciplinary team was assembled to address combining the roles, concluding that the ICU charge nurse role wasn't appropriate for combination due to a vast number of responsibilities (RRT, STEMI team, code blue team, trauma team, and other unit needs). These conversations created an opportunity to introduce a new component to the role of the ICU charge nurse, incorporating proactive monitoring with RRT responsibilities. There were many names for this in the literature, but the team decided to title the role critical care consult nurse.

The critical care consult nurse would continue to function as the ICU charge nurse, assuming all the responsibilities of that role and monitoring at-risk patients utilizing the Rothman Index. The critical care consult nurse wouldn't take a patient assignment to ensure that they could be off the unit for extended periods if needed. This ability to leave the unit promoted communication and collaboration between the critical care consult nurse and the primary nurses caring for at-risk patients.

The team collaborated on the criteria required for a patient to be evaluated by the critical care consult nurse. A primary nurse could consult the critical care consult nurse for assistance with managing patients experiencing heart rate changes, BP variances, and changing mental status or level of consciousness or out of general concern for the patient's condition. The critical care consult nurse would prioritize consults based on the type of alert generated and the at-risk patient's location. The nursing units with the highest priority were progressive care and medical-oncology due to the complex health issues encountered on these units and the increased probability of a condition decline. The Rothman Index collected much of this information, making the data readily accessible to the critical care consult nurse for timely in-person or telephone follow-up with the primary nurse.

The critical care consult nurse would meet the primary nurse and assess the patient's condition for further information. Together, the primary nurse and the critical care consult nurse would collaborate on the next steps needed and form a plan for the patient. The care plan could require monitoring, intervention from the physician for treatment orders, or an RRT call. The critical care consult nurse would follow up at the end of the shift to evaluate how the patient was responding to the treatment plan or if there was a need to escalate the level of care. The critical care consult nurse was to be available on each 12-hour shift, covering both day and night shifts.

During this time, the hospital was upgrading its Rothman Index product. The new product has advanced capabilities to monitor at-risk patients based on physiologic data and nursing assessment. The alerting component advises an escalation of clinical care based on a score calculated from EMR information, ranging from a maximum score of 100 to a minimum of -91. A scaling factor ensures that most medical-surgical patients fall within the 0 to 100 range, with higher scores signifying clinical stability. A falling score indicates clinical deterioration.5 Three risk warnings are generated: a medium-risk alert when the score drops more than 30% in less than 6 hours, a high-risk alert for a drop more significant than 50% in less than 24 hours, and a very high-risk alert for a value of less than 20.3,7

To identify at-risk patients in the hospital, the critical care consult nurse would utilize the new electronic display component of the Rothman Index to monitor alerts by visualizing the scores on a color-coded line graph. Before implementation, nurses who participated in the RRT or were current charge nurses were identified for training as critical care consult nurses. These nurses received specific training and focused education on updates to the Rothman Index, its new electronic display component, and the process for completing consults.


The purpose of the pilot was to determine if the implementation of a critical care consult nurse accompanied with upgraded early warning system software would decrease inpatient code blue emergencies and mortality. The goals were to decrease inpatient code blue emergencies by 20% and reduce the hospital mortality index by 30%. Before the pilot project's implementation, the inpatient code blue rate was 8.05 per 1,000 discharges, with a mortality index of .97 in fiscal year (FY) 2017.

The pilot took place from October 2017 to February 2018. During this time, the critical care consult nurse performed consults for 175 patients, logging the encounters in an electronic spreadsheet.

After the pilot completed in February 2018, the critical care consult nurse role continued as an integrated part of the ICU charge nurse role. The inpatient code blue rate and mortality index continued to be trended as nursing leadership worked to create a business case for a full-time, stand-alone position. In September 2018, the critical care consult nurse role was taken to the position review committee and approved as a full-time position in the ICU, now called the high-acuity response team nurse.


During the pilot, there was an improvement in the mortality index but the inpatient code blue rate remained unchanged. (See Figures 1 and 2.) Data were analyzed to understand how the critical care consult nurse role had impacted these factors over time and to measure the attainment of program goals. Preimplementation data were analyzed from May 2017 to August 2018; postimplementation data were analyzed from September 2018 to March 2019.

Figure 1::
Mortality index
Figure 2::
Inpatient code blue rate per 1,000 patient days

The overall implementation of the high-acuity response team nurse position resulted in a 34% decrease in inpatient code blues (pre, N = 182; post, N = 47). The inpatient code blue rate decreased from 8.05 per 1,000 patient days to 5.31 per 1,000 patient days. A two-sample Poisson test didn't reflect a statistically significant decrease in the code blue rate (z = 1.05, P = .294, 95% CI -1.03872-3.43623); however, the decrease was clinically significant. There was a 35% decrease in mortality after implementation of the high-acuity response team nurse as a standalone role. The mortality index reflected a statistically significant decrease from .97 to .63 (t (28) = 4.15, P = .000).


Overall, the pilot was successful and led to implementation of a permanent high-acuity response team nurse position. The hospital was able to significantly decrease the number of inpatient code blue emergencies and improve the mortality index with the permanent position. As supported by the literature, the use of an early warning system in conjunction with a proactive rounding approach prevented failure to rescue events from occurring.

In addition, interprofessional collaboration between critical care nurses and various nursing specialties throughout the hospital was improved with this intervention. Often, night-shift nurses have fewer years of nursing experience than nurses on the day shift. Night-shift nurses' interactions with the critical care consult nurse/high-acuity response team nurse provided mentoring moments on clinical conditions with corresponding physiologic changes to expand the knowledge base of the novice nurses.


There were limitations noted during the pilot. Communication regarding the critical care consult nurse role and responsibilities didn't occur hospital-wide in mass education. Rather, communication was by word of mouth and focused training within the ICU. This rollout strategy made it difficult to operationalize the critical care consult nurse role hospital-wide. Often, the critical care consult nurse would visit nurses who hadn't heard of the initiative. The critical care consult nurse took time to educate the nurses and explain the purpose of the consult and visit.

Another limitation was that the critical care consult nurse role wasn't a stand-alone, 24/7-designated position. As mentioned before, this was another component of the ICU charge nurse's responsibilities. There were many times when conflicting priorities and unit needs took precedence over consults. The team felt that the pilot outcomes may have seen more significant improvement if the critical care consult nurse was in a different position than ICU charge nurse.

During the last quarter of the pilot, a new throughput model was introduced, including a centralized hub of personnel to assist with hospital throughput. The lead nurse at the center of the model was the clinical care coordinator, an RN responsible for placing patients into the appropriate areas. Screens were placed in the hub, with the Rothman Index displayed. When an alert was generated, the clinical care coordinator would immediately reach out to the primary nurse of the patient who generated the alert, requesting the patient be evaluated immediately. The clinical care coordinator monitoring alerts allowed for 24/7 coverage.

Be proactive for positive outcomes

The critical care consult nurse role is a proactive component of the RRT to identify at-risk patients and provide early intervention. After implementation of the full-time high-acuity response team nurse position, the hospital saw marked improvements by reducing the number of code blue events outside the ICU by 34% and the mortality index by 35%. The high-acuity response team nurse position was implemented as a full-time role in fall 2018 and continues to be a functional role of the ICU nursing team.

Nurse leaders are critical stakeholders in implementing a role such as the critical care consult nurse. The pilot and subsequent permanent implementation of the high-acuity response team nurse position were championed by critical care nurse leaders. The nurse leaders' advocacy promoted critical care nurses' professional development and sought resources for the unit to provide this role with full-time coverage. Permanent implementation of the high-acuity response team nurse position has led to a positive improvement in quality outcomes and strengthened critical care nurse mentorship and teamwork.


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