Risks of Mortality Associated with Nursing Assessments:

1. 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. 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. 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. 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

5. Clinical Implications – 30-day mortality … Last assessment All p-values < 0.001, except for pain, with a p-value of 0.474

6. Clinical Implications – 1-year mortality … Last assessment All p-values < 0.001, except for pain, with a p-value of 0.474

7. Clinical Implications – In-hospital mortality

8. Clinical Implications – Nursing Assessments • If the first nursing assessments taken upon admission correlate with in-hospital mortality… and • Thelastnursing assessments taken prior to discharge correlate with post-discharge mortality… then • It is reasonable to infer thatallnursing assessments gathered throughout the patient’s stay contain significant clinical information

9. 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.