Applying the Rothman Index to Reduce Mortality: Oconee Memorial’s Bold Push

Oct. 5, 2016
One South Carolina hospital is leveraging a commercialized solution that brings the value of the Rothman Index directly to nurse managers, to reduce patient mortality, improve clinical outcomes, and enhance efficiency

One South Carolina hospital is leveraging a commercialized solution that brings the value of the Rothman Index directly to nurse managers, in order to reduce patient mortality, improve clinical outcomes, and enhance efficiency

At Oconee Memorial Hospital in Seneca, South Carolina, clinician and clinical informatics leaders are making major strides in monitoring patients for sudden changes in medical condition. Oconee Memorial is a 169-bed community hospital in a small town located halfway between Charlotte and Atlanta. There, Sarah James, R.N., the hospital’s nursing information systems coordinator, has been helping to lead an initiative that is already paying dividends.

James and her colleagues have been partnering with the Charlotte-based PeraHealth, a vendor whose core solution has helped to operationalize the use of the Rothman Index in order to support the optimal monitoring of patient conditions. The Rothman Index, as explained in a Wikipedia entry on the subject, “captures data found in a hospital's electronic health record and displays the progression of a patient's health over time. The Rothman Index generates a regularly updated health score synthesizing routine vital signs, nursing assessments, and lab results, for display in a user-friendly graphical format, summarizing thousands of pages of patient data at a glance. The Rothman Index simplifies the tracking of patient progress and detects subtle declines in health. Rapid response teams, physicians and nurses have the ability to see multiple patient graphs simultaneously. This allows for earlier interventions and a summarized understanding of a whole unit, providing patients with the extraordinary care they need effectively and efficiently.”

As the Wikipedia entry also notes, “The Rothman Index is named in honor of Florence Rothman. In 2003, Florence underwent an operation to replace a heart valve at Sarasota Memorial Hospital. Although her health initially improved after the operation, it gradually worsened until she died 10 days after the operation. Her sons Michael and Steven Rothman determined that it was the overall system of care that failed her by not detecting her gradual health deterioration. Their solution was to develop a simple measure of a patient’s overall condition that can be plotted versus time to show a doctor or a nurse whether a patient is recovering or deteriorating. They worked with Sarasota Memorial Hospital by analyzing thousands of patient records in the Electronic Health Record to develop the Rothman Index.” David and Michael Rothman had worked with David Classen, M.D. the CMIO at the Washington, D.C.-based Pascal Metrics, to develop the core of the Index, according to a 2013 article by Craig Clapper of Healthcare Performance Improvement.

Sarah James spoke recently with HCI Editor-in-Chief Mark Hagland about the Oconee Memorial initiative in this area. Below are excerpts from that interview.

What is the background to your current initiative? And what have been your broad operational goals in pursuing it?

We implemented our current EHR [electronic health record] in April 2013; it’s McKesson’s Paragon. So with that, we were presented with this huge array of information. It’s the same challenge hospitals are facing everywhere; we have all this information, and the question is, what do you do with it? And the solution for us was ParaTrend. It came to us through our CEO, who had seen a demo of it and who had offered it to our CNO as a solution to help nursing interpret this massive amount of information. That’s why we initially started looking at ParaTrend. And we realized it could also reduce the number of rapid responses and Code Blues, and could help us intervene earlier in situations where patients were declining. That perked up our CNO’s ears, and she was immediately on board, so we began a project using that solution in February of this year [2013]; by April or May, we were digging in pretty deep.

The nursing assessment and lab reports and vital signs are run through the Rothman Index algorithm, and it creates an individual patient score. It runs from 0 to 100, with 100 being a totally healthy person. As the number goes down, that correlates to the risk for mortality. So each patient has a graph that’s updated, based on however frequently your system is running. Our system updates the graph every five minutes. So currently, the way we’re using it is that our nursing supervisors, when doing handoffs shift to shift, are pulling up the entire hospital on a computer monitor—and the solution allows for patients with significant drops, based on parameters we choose—it puts them into “swim lanes” that draw your attention to them. It could be based on a certain percentage drop in the Rothman Index, or based on a certain number of points. There are typically three levels of risk: very high risk, high risk, and moderate risk.

So a patient who dropped from, say, 45 to 25, would probably flash in the dashboard as an alert?

Yes, that’s correct. And the beauty of it is that, at a moment’s glance, you can have a pretty good idea of what’s going on in the hospital. For a nursing supervisor, with all that they’re in charge of, that’s very valuable, and you can see where the hot spots are, and what’s going on. That’s especially true in terms of acuity and staffing. If you’ve got one unit with particularly high acuity, you can address that. And so the nursing supervisors are looking at this at every shift change. And usually the outgoing night shift supervisor and CNO meet in the morning to assess staffing levels and interventions. Do we need to more a patient into the critical care unit, or need to get someone to call a physician?

That is just the tip of the iceberg for the uses we have planned for rolling the out program out more broadly. We’ve got great ideas about using it for staffing purposes. For example, you wouldn’t want to assign the same nurse four or five high-acuity patients. So if you have a patient who’s a 45, their graph would turn red if they dropped below 40. That’s a graphic indicator. And our charge nurses will continue to use it. And as we roll out to all clinical areas in 2015, we really want to look at palliative care—to give people a concrete, objective number that you can use to trigger palliative care consults. That sort of takes the emotion out of it and helps to be able to initiate a conversation. There was a study done where end-of-life decisions were made easier by the Rothman, because it’s a concrete number. You can say this condition is associated with this level of mortality; or this downward trend is a visual indicator of their decline.

Do you have any metrics or measurements yet to share?

We currently don’t. We’re so early in the process of measurement. We plan to measure the number of Code Blue and rapid responses; we’re too early to have data yet, but we expect to see that measure reduced through early intervention. Other measure items we’re looking forward to in 2015—we’re hoping to reduce readmissions; and we’d like to see the number of palliative care consults go up.

So the solution has been implemented in some units, then, but not all, correct?

All nurse managers in the hospital are familiar with it, and all units are familiar with it. It’s available in all units, and we’ve even included case management and our quality improvement folks, in the training. Case management was very excited, and they’re looking to use it in discharge disposition—to make sure we’re discharging patients to the right location. If a patient is too low on the Rothman scale—if a patient is below 65 or 70, the chance of them coming back within 30 days is significant—it’s something like 60 percent. That’s a pretty strong indicator. So using the PeraTrend graph for overall trends and using the Rothman Index at the time of discharge, could be very helpful.

What lessons have been learned from this early phase of implementation?

Well, the first thing we learned was how little folks had been paying attention to nursing documentation. Implementing the solution all of a sudden put nursing documentation under the microscope; so the quality and timeliness of nursing documentation suddenly mattered. So nurses felt themselves to be under scrutiny, but they also felt validated, because the documentation that they’re spending 50 percent of their time on, is impacting physicians. And you can see the quality and importance of nursing documentation, because if there’s no activity, there’s no documented change.

In terms of other lessons, when this solution was presented to a small group of our physicians, they had questions about the legal status of this information that would now be discoverable legally; so we had to reassure them that this was information that was already in the medical record. The fact that a patient has not had a bowel movement in five days, for example, that’s already in the medical record.

What would you say to healthcare IT leaders about this? It does seem as though it offers a real opportunity for collaboration between clinician leaders and healthcare IT leaders.

Yes, absolutely. The beauty of this product is that it’s taking something already there and turning it into something of value, or exponentially increasing the value of something that’s already there. With EHRs, everybody’s facing the big-data problem, and now we have this, and it’s a feasible tool that’s relatively easy to implement, and it involves taking something that’s already there but which is relatively easy to implement. What’s more, for IT people, this is really something that requires low involvement once you get it going; but the value is extreme. So there’s a lot of return on investment.

It seems like this is another opportunity to help nurses and physicians intervene together quickly.

Yes. Interdisciplinary rounds is something we’re working on. And using PeraTrends as part of interdisciplinary rounds really keeps everyone on page. Speaking as a nurse, ParaTrend can help the nurse by corroborating her or his intuition. Often as a nurse, you have a sense that the patient isn’t doing well. And this offers another resource to give us a concrete picture of what’s going on with a patient. And even with a new nurse, this helps that nurse communicate with the physician. We’re careful that we don’t want nurses calling a physician saying, your patient has a Rothman index of 28, what are you going to do about that? Instead, the nurse can say, the patient’s index is 28 because of A, B, and C, and it gives a little substance to the report.

Is there anything else you’d like to add?

I think one of the perks of PeraTrend is that the graphic element really does simplify the interpretation of the data; it helps the user quickly assess what’s going on. You’ve heard the expression, “drinking from a fire hose”? This helps bring the level down to a drinking-fountain level of information input, and quickly helps you assess what’s going on with a particular patient.