At the start of my shift, at 7 a.m., my patient, newly admitted a few days before for a blood cancer, was talking and acting normally. By the end of my shift, 12 hours later, she had grown confused and her speech was garbled. A CT scan revealed bleeding in her brain. She was sent to intensive care and died the next day.
This was years ago, but the case still haunts me. I believe that moving faster on her treatment might have prevented her sharp decline. But the medical team didn’t share my sense of urgency, and no obvious red flags signaled a coming emergency. Without a worrisome clinical value or test result to point to, my concern alone wasn’t persuasive.
Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.
In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble.
These reactions and observations typically aren’t given the clinical weight of test results and lab values. Similarly, a large part of every nursing shift is spent on the computer documenting how patients are doing, but the content of these notes is more often than not ignored, particularly by physicians.
It doesn’t have to be this way, and it may not be for much longer. The change began in 2003, when an 87-year-old woman named Florence Rothman was hospitalized for a heart-valve replacement. She was in good health and initially did well, but experienced a slow, unnoticed deterioration in the hospital. She eventually received treatment for her symptoms, but no one investigated the cause. However, she improved and was sent home.
Four days later Ms. Rothman was seen by a home health nurse during an episode of severe breathlessness. When it happened again the same day, her family called 911, but it was too late: Her heart stopped in the emergency room, crushed by fluid surrounding it.
Ms. Rothman’s sons — Michael, an engineer, and Steven, a data scientist — wondered if their mother’s death could have been avoided, had there been a better way to track her signs of distress. Doctors later determined that she had developed a condition called cardiac tamponade, and it probably started during that first deterioration in the hospital. If her overall condition had been thoroughly examined at that point, the tamponade likely could have been detected and treated.
Together the Rothman brothers came up with the Rothman Index, a commercial product that uses data from standard electronic health records — including lab values, vital signs, cardiac rhythms and key aspects of nursing assessments — to monitor hospital patients. It tracks their status as a graph that falls into a blue, yellow or red zone, based on whether they are at low, medium or high risk of an acute event. Michael Rothman said cartoons about hospitals that show a chart with a zigzag line appended to the foot of each patients’ bed reflect the visual power of the Rothman Index.
The goal is to identify those patients who might look stable but are in fact fragile; applied correctly, it allows medical teams to intervene well before a crisis hits. This saves lives, and money. I have seen the Rothman Index in action at the Yale New Haven Health System, where special SWAT team nurses use it to coordinate care for the sickest patients.
The Rothman Index empirically validates nurses’ gut feelings by showing that nursing assessments — what nurses see and document when they “lay eyeballs” on patients — offer crucial information about patient stability. It validates what nurses have known all along: that well-honed clinical instincts matter.
Part of why I still feel haunted by my patient who suddenly took a turn for the worse and then died is because of that nagging sense I had, early on, that something was wrong. Her disease put her at risk for spontaneous bleeding, but at the start of her third day in the hospital a treatment plan still wasn’t in place. My gut told me we were moving too slowly, and I was able to push here and there. But there was nothing I could articulate as a sign of impending calamity.
I don’t have access to that patient’s records, so I can’t go back and chart her Rothman Index. But I can promise myself that in the future, I will take any sense of urgency very seriously, document my concern and speak up. There’s now solid evidence that when a nurse says she’s got a bad feeling about a patient, the entire care team needs to listen.
Theresa Brown, a hospice nurse, is the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.”