1© RHC 2011 – Confidential Visualizing Patient Health

Risks of Mortality Associated with Nursing Assessments:

A Quantitative Indication of their Reliability, Validity and Clinical

Implications

Michael Rothman, PhD, Alan Solinger, PhD, Steven Rothman,

MSEE, G. Duncan Finlay, MD

Rothman Healthcare Corporation

September 13, 2012

2© RHC 2012 Visualizing Patient Health

Motivation

• Florence Rothman died in a hospital, in part because of fragmentation of care; she deterioratedslowly across shifts…

• To make deterioration visible, we built an acuity model… looking at all EMR data including nursing assessments

• Nursing assessments:– 50% of a hospital’s operating budget goes to nursing, 50%

of which is computer entry… but the data is not used– From physicians, we found skepticism as to the significance

of nursing assessments

3© RHC 2012 Visualizing Patient Health

Simplified Nursing Assessments

• “Head-to-toe” assessments - part of standard nursing school curricula

• Simplified… “charting by exception”… the patient has either “met” or “not met” a minimum standard– GI standard - Abdomen soft and non-tender. Bowel sounds present.

No nausea or vomiting. Continent.

• Nursing assessments are recorded twice each day

• Every hospital records essentially the same data

4© RHC 2012 Visualizing Patient Health

Data

• 42,302 patient visits from two 1-year periods at an 805-bed community hospital

• Excluded data from patients under age 18, as well as psychiatric and maternity

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Clinical Implications – 30-day mortality … Last assessment

Nursing Assessment

MetLive

MetDied

Odds Not metLive

Not metDied

Odds OddsRatio

Food 34769 705 0.02 3383 1084 0.32 16

Neurological 34600 770 0.02 3561 1018 0.29 13

Psychosocial 36327 1260 0.04 1834 525 0.29 8.3

Cardiac 31947 1119 0.04 6228 670 0.11 3.1

Pain 33618 1568 0.05 4436 218 0.05 1.1

All p-values < 0.001, except for pain, with a p-value of 0.474

6© RHC 2012 Visualizing Patient Health

Clinical Implications – 1-year mortality … Last assessment

Nursing Assessment

30-day Odds Ratio

1-yearOdds Ratio

Food 16 6.7

Neurological 13 6.5

Psychosocial 8.3 5.3

Cardiac 3.1 2.3

Pain 1.1 0.8

All p-values < 0.001, except for pain, with a p-value of 0.474

7© RHC 2012 Visualizing Patient Health

Clinical Implications – In-hospital mortality

Neurological

Respira

toryFo

od

Musculoske

letal

Psychoso

cial

Safety Sk

in

Peripheral V

ascular

Genitourin

ary

Cardiac

Gastrointesti

nalPain

02468

10 9.48.1

7 6.9 6.75.6 5.2

3.93 2.8 2.3

1.1

Odds Ratios – First assessment

8© RHC 2012 Visualizing Patient Health

Clinical Implications – Nursing Assessments

• If the first nursing assessments taken upon admission correlate with in-hospital mortality… and

• The last nursing assessments taken prior to discharge correlate with post-discharge mortality… then

• It is reasonable to infer that all nursing assessments gathered throughout the patient’s stay contain significant clinical information

9© RHC 2012 Visualizing Patient Health

Conclusion – Simplified Nursing Assessments• A “new” longitudinal source of clinical information

• Important as input data for an acuity model (Rothman Index)

• Creates the potential to help nurses and physicians see deterioration and improve the continuity of care

For more information … michael@rothmanhealthcare.com

Reference – Rothman, MJ, Solinger, AB, Rothman, SI and Finlay GD, Clinical Implications and Validity of Nursing Assessments: A Longitudinal Measure of Patient Condition from Analysis of the Electronic Medical Record. BMJ Open 2(4) 2012.