By Pamela K. Greenhouse, MBA,
                                                                           Beth Kuzminsky, M...
Josie’s heart stopped as I was rubbing her          patient participation always beneficial for the
         feet. Her eye...
But rapid response teams generally can be             Table 1. Signs and Symptoms of Impending Patient Crisis
summoned onl...
members and any staff who were involved review          dled on a case-by-case basis. For example, in the
     verbally th...
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Calling a Condition "H"


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Calling a Condition "H"

  1. 1. By Pamela K. Greenhouse, MBA, Beth Kuzminsky, MSN, RN, Susan C. Martin, MSN, RN, and Tamra Merryman, MSN, RN Calling a Condition H(elp) One facility gives patients and families the ability to summon a rapid response team. n January 2001, an 18-month-old girl I named Josie King died as a result of hospital errors at Johns Hopkins Medical Center in Baltimore, Maryland. Hospitalized for first- and second-degree burns she’d suffered in a bathtub accident, Josie had reportedly been “heal- ing beautifully,” and a speedy recovery was expected.1 But two days before she was to return home, Josie died from “severe dehydration and misused narcotics.” Speaking at the national conference of the Institute for Healthcare Improvement (IHI) in October 2002, Sorrel King described the series of Courtesy of the Josie King Foundation errors that led to her daughter’s death1: [H]er central line had been taken out. I began noticing that every time she saw a drink she would scream for it, and I thought this was strange. I was told not to let her drink. While a nurse and I gave her a bath, she sucked furi- ously on a washcloth. As I put her to bed, I noticed that her eyes were rolling back in her head. Although I asked the nurse to call the doctor, she reassured me that oftentimes chil- Sorrel King and her daughter Josie, who at 18 months was hos- dren did this and her vitals were fine. I told her pitalized for treatment of burn injury and died as a result of hos- Josie had never done this and perhaps another pital error in 2001. ‘Josie’s death was not the fault of one nurse could look at her. After yet another reas- doctor, or one nurse, or one misplaced decimal point,’ King has said. ‘It was the result of a total breakdown in the system.’ She surance from another nurse that everything was has been an advocate of allowing patients and family members fine, I was told that it was OK for me to sleep to call for a rapid response team when they deem it necessary. at home. . . . [But the next morning] she was not fine. Josie’s medical team arrived and administered two shots of Narcan [naloxone]. I asked if she could have something to drink. sat with Josie, I noticed that the nurse on morning The request was approved, and Josie gulped duty was acting very strangely. She seemed nerv- down nearly a liter of juice. Verbal orders were ous, overly demonstrative, and in a hurry. . . . issued for there to be no narcotics given. As I I expressed my concern to one of the doctors, and he agreed that she was acting a bit odd. Pamela K. Greenhouse is an associate to the vice president, Meanwhile, Josie started perking up. She was Center for Quality Improvement and Innovation (CQII), more alert and had kept all liquids down. I was University of Pittsburgh Medical Center, Pittsburgh, PA. Beth Kuzminsky is a staff associate, Susan C. Martin is the director, still scared and asked her doctors to please stay and Tamra Merryman is the vice president of the CQII. Tamra close by. At 1:00 [pm] the nurse walked over Merryman has consulted for the Institute for Healthcare with a syringe of methadone. Alarmed, I told Improvement. Contact author: Pamela K. Greenhouse, her that there had been an order for no nar- (412) 647-6024 or Emergency is coordinated by Polly Gerber Zimmermann, MS, MBA, RN, cotics. She said the orders had been changed CEN: and administered the drug. AJN M November 2006 M Vol. 106, No. 11 63
  2. 2. Josie’s heart stopped as I was rubbing her patient participation always beneficial for the feet. Her eyes were fixed, and I screamed for patient? These questions are difficult to answer. help. I stood helpless as a crowd of doctors and nurses came running into her room. I was ush- RAPID RESPONSE AT UPMC ered into a small room with a chaplain. The At UPMC Shadyside, designated teams have been next time I saw Josie she had been moved back responding to in-hospital emergencies for several up to the [pediatric ICU]. Doctors and nurses years. Calls are termed condition A (cardiac or were standing around her bed. No one seemed respiratory arrest requiring cardiopulmonary resus- to want to look at me. . . . [Two days later] citation [CPR]) or condition C (crisis). Many hospi- Josie was taken off of life support. She died in tals have separate and distinct CPR (condition A) our arms on a snowy night in what’s considered and rapid response (condition C) teams.4 However, to be one of the best hospitals in the world. . . . at our hospital the same core team—led by an ICU Josie’s death was not the fault of one doctor, or physician and including a nurse anesthetist, a respi- one nurse, or one misplaced decimal point. It was ratory therapist, family practice and internal medi- the result of a total breakdown in the system. cine residents, an advanced practice nurse, two ICU In December 2004, Ms. King reprised her nurses, an administrative nursing coordinator, and speech at the IHI’s national forum on behalf of the the staff nurse caring for the patient—responds to institute’s 100,000 Lives Campaign. Addressing both kinds of calls. It’s important to have the full one of the campaign’s proposed interventions— team present in a condition C situation deteriorat- rapid response teams—Ms. King proposed that ing into a condition A situation. It’s also more parents be able to initiate a call. One of the effective to release some responders if they aren’t authors of this article, Tamra Merryman, then–vice needed than to call additional responders. (For president of Patient Care Services at University of more on rapid response teams, see “Implementing a Pittsburgh Medical Center (UPMC) Shadyside Rapid Response Team,” October.) Hospital in Pittsburgh, Pennsylvania, was in the Criteria for calling a condition A are straightfor- audience. Ms. Merryman took this idea back to ward: when a patient is pulseless or not breathing UPMC Shadyside and, with the support of hospital or both and requires CPR. However, a clinician leadership, developed it. Condition H (the H stands may call a condition C whenever “something is just for “help”), a mechanism by which patients, fami- ‘not right’ with a patient, but he doesn’t meet code lies, and visitors can initiate a rapid response team criteria.”4 The IHI has identified signs and symp- call, was implemented at UPMC Shadyside in May toms of clinical instability that may indicate an 2005. (The King family has provided monetary impending cardiac arrest5, 6; UPMC Shadyside and a support for condition H programs at UPMC sister hospital, UPMC Presbyterian, have developed Shadyside and elsewhere. For more about the Josie additional guidelines regarding any changes “that King Foundation’s work promoting patient safety, should raise a red flag. . . . These criteria are posted go to in every nursing unit and distributed to all new staff members.”4 (See Table 1, page 65.) FROM PATERNALISM TO PARTNERSHIP An analysis of unpublished data from UPMC Until fairly recently, physicians traditionally assumed Shadyside alone shows that between December 1, sole responsibility for treatment decisions—a pater- 2004, and November 30, 2005, there were 171 con- nalistic approach wherein the physician’s authority dition A calls (involving 159 patients) and 699 condi- was rarely challenged by patients and families.3 tion C calls (involving 601 patients). When mortality Within the past 30 years or so, that approach has rates are calculated based on the number of patients, shifted slowly toward a model of care in which, 50.3% of the condition A patients and 19.3% of the ideally, health care professionals, patients, and fam- condition C patients died. Moreover, at UPMC ilies make decisions in equal partnership. Patient Shadyside and UPMC Presbyterian, the number of rights and responsibilities are often emphasized in condition C calls has increased significantly during health care today, and the benefits of including the past two years, whereas the number of condition patients and families in decision making, as well as A calls has decreased. As Scholle and Mininni stated, providers’ obligation to do so, may seem clear. Yet “By proactively responding to [life-] threatening situ- in clinical practice, it has proven difficult to achieve ations, the [medical emergency team] program has such a partnership. When should a patient and reduced the number of patients who progress to car- family participate in decision making? Whose diac arrest by 30% and reduced the rate of unex- responsibility is it to ensure their participation? Is pected mortality by 27%.”4 64 AJN M November 2006 M Vol. 106, No. 11
  3. 3. But rapid response teams generally can be Table 1. Signs and Symptoms of Impending Patient Crisis summoned only by providers, not by patients and families. What Sorrel King’s story revealed was Signs and Symptoms of Clinical Instability Before Arrest that patients and families may recognize signs that a patient is deteriorating before physicians and Mean arterial pressure lower than 70 or higher than 130 mmHg nurses do. Moreover, some patients may not have Heart rate lower than 45 or higher than 125 beats/minute round-the-clock nursing care: family members may Respiratory rate lower than 10 or higher than 30 breaths/minute not be able to reach the nurse quickly, and the Complaints of chest pain rapid response team call will be delayed. Some Change in mental status nurses, concerned about sounding a false alarm, might wait before taking action. Condition H Additional UPMC Shadyside–Presbyterian Signs and Symptoms offers patients and families a way to initiate the of Clinical Instability call themselves. Chest pain unrelieved by nitroglycerin CONDITION H Sudden loss of movement or weakness in face, arm, or leg How it works. At UPMC Shadyside, all patients Change in color of central or peripheral skin (to pale, dusky, and families upon admission receive guidelines gray, or blue) regarding condition H and a telephone number for Unexplained agitation lasting more than 10 minutes calling the condition H team. This team differs Bleeding into the airway from the team that responds to condition A and C calls. Our condition H team is led by an adminis- Franklin C, Mathew J. Crit Care Med 1994;22(2):244-7; Institute of Healthcare trative nursing coordinator and includes a physi- Improvement. Getting started kit: rapid response teams: how-to guide. 2006 Jun. cian from internal medicine, a patient relations RRTHowtoGuideKathyUpdatev19postedtoweb60806.doc; Scholle CC, Mininni NC. coordinator, and unit nursing staff. The telephone Nursing 2006;36(1):36-40. number is a direct inside line to a hospital opera- tor, who asks for caller identification, the room number, the patient’s name, and the caller’s con- The guidelines do not seek to limit severely the cern. The call immediately activates condition H circumstances under which a family member might by sending a message to team members’ pagers call a condition H. Rather, the goal is to involve and announcing the condition H on the hospital’s families more substantially in patient care, so as to public address system. The response team then minimize the likelihood of errors such as those arrives in the patient’s room and assesses the situa- that led to tragedy for the King family. tion. Additional clinical support is called in as Staff response and patient follow-up. Condition needed. (All calls to the condition H number are H was initially tested on a 24-bed medical cardiol- treated as true condition H calls, with the excep- ogy unit at UPMC Shadyside that was participat- tion of calls expressing concerns about diet, ing in an IHI–Robert Wood Johnson Foundation requests for geographic directions, basic environ- initiative called Transforming Care at the Bedside.7 mental concerns such as room temperature, or Initial responses from patients, families, and the requests for housekeeping. Such calls are rerouted pilot unit staff were favorable, and the program to the patient relations coordinator, who addresses was expanded hospital-wide. the caller’s needs.) As Richard Lippe, MD, an admitting physician On the patient’s unit, the admitting nurse at UPMC Shadyside, has observed, “Condition H reviews condition H guidelines with patients and gives to our patients a sense of empowerment and families. (In the near future, the hospital plans to security—something we all need in times of diffi- supplement this with television-based patient edu- culty.” However, some skepticism and wariness cation.) The guidelines state that a condition H call among nurses and physicians have been evident. should be made Some staff were concerned that patients and fami- • if a noticeable change in the patient’s condition lies would make condition H calls for nonemer- occurs and the health care team isn’t responsive gency needs; others, particularly nurses, worried to either the change itself or to patient and fam- about the implications of “having an H called on ily concerns. my watch.” • if there is a breakdown in how care is being Each condition H call is handled independently given or confusion over what needs to be done. by the responding team. Once the patient has been • if both of these occur. stabilized (or transferred), the responding team AJN M November 2006 M Vol. 106, No. 11 65
  4. 4. members and any staff who were involved review dled on a case-by-case basis. For example, in the verbally the events that led to the call. The empha- case of the patient who called a condition H sis is on learning rather than on judgment; what is because the physician hadn’t adequately explained learned is then shared with all hospital staff and the need for blood transfusion, the vice president leadership. Twenty-four hours after every condi- of Patient Care Services met with the physician tion H call, the patient is visited by the patient and shared the report from the patient’s post– relations coordinator and a bedside interview is condition H meeting. The physician welcomed the conducted. (If a family member called the condi- feedback and realized he needed to provide more tion H, that person may also be present.) This fol- time for patient questions. low-up provides further opportunity for hospital One patient called a condition H because he personnel to learn from patients and families. This was experiencing severe pain during physical ther- approach is helping to lessen staff concerns about apy. As a result, hospital protocol now recom- condition H. mends that all patients on that unit (an oncology unit) be offered pain medication before physical NINE MONTHS IN therapy. In its first nine months at UPMC Shadyside, condi- Patient and family response. Interviews con- tion H was initiated 21 times. Analysis of these ducted with patients and families involved in the events indicates that the majority of condition H 21 condition H calls have yielded unanimously calls met at least one of the two criteria. Most of favorable responses toward the program. Typical the calls were related to communication issues were comments such as “[Condition H] makes me between patients and clinicians and fell into two want to come to UPMC Shadyside even more, broad categories. In some cases, the patient and should I or a family member need medical care family wanted better explanations of the treatment again” and “Having condition H available makes and care plan (for example, one patient had con- me feel safer, respected, and empowered.” cerns about receiving a blood transfusion and felt Although none of the first 21 condition H the physician hadn’t adequately explained why it calls at UPMC Shadyside definitely saved a life was needed). In others, the patient and family dis- or averted a health care crisis, future calls may agreed with the treatment or care plan (or both) do so. At the least, the program has enhanced the and didn’t feel their concerns were receiving enough partnership among patients, families, and clini- attention (for example, a patient was prescribed a cians. Data collection is ongoing, and as the condi- medication that had previously caused an adverse tion H program matures and the sample of calls reaction and was questioning its having been increases, the data will be analyzed further, with ordered now). Five of the 21 condition H calls particular attention to be given to averted adverse were related to a need for more effective pain man- events and reduced risk. M agement, one was made by a nurse who was hav- ing difficulty contacting a physician, and three REFERENCES were made mistakenly (for example, one patient 1. King S. Sorrel’s speech to IHI conference. Institute for misunderstood whom to call for routine needs and Healthcare Improvement National Conference; 2002 October 11; Boston. made a condition H call instead of using the call 2. Remaking American Medicine. Champion of change: Sorrel bell). One condition H was called by a patient King, parent and family-centered care advocate. http://www. with chest pain who had been waiting to be seen in the ED and felt no one was available to respond. 3. Charles C, et al. What do we mean by partnership in mak- ing decisions about treatment? BMJ 1999;319(7212):780-2. Dealing with issues raised. To address commu- 4. Scholle CC, Mininni NC. Best-practice interventions: how a nication issues among staff, the hospital has rapid response team saves lives. Nursing 2006;36(1):36-40. adopted a situational briefing model known as 5. Franklin C, Mathew J. Developing strategies to prevent SBAR (the acronym stands for situation, back- inhospital cardiac arrest: analyzing responses of physicians ground, assessment, recommendation) to promote and nurses in the hours before the event. Crit Care Med 1994;22(2):244-7. more effective communication among staff. 6. Institute of Healthcare Improvement. Getting started kit: rapid (For more about SBAR, see response teams: how-to guide. 2006 Jun. Topics/PatientSafety/SafetyGeneral/Tools/ NR/rdonlyres/6541BE00-00BC-4AD8-A049-CD76EDE5F171/ 0/RRTHowtoGuideKathyUpdatev19postedtoweb60806.doc. SBARTechniqueforCommunicationASituational 7. Institute for Healthcare Improvement. Transforming care BriefingModel.htm.) Communication issues involv- at the bedside. ing patients, families, and clinicians have been han- TransformingCareAtTheBedside. 66 AJN M November 2006 M Vol. 106, No. 11