Improving outcomes with new roles

A medical center in Vero Beach, Fla., reduced code blues and implemented multi-disciplinary rounds through a patient safety and quality initiative.

Where: Indian River Medical Center, a 335-bed acute care hospital in Vero Beach, Fla.

The issue: Reducing code blues and implementing multi-disciplinary rounds.


In 2010, Indian River Medical Center began a new initiative. “This patient safety and quality initiative had several pillars—one was implementing multi-disciplinary rounds throughout the hospital, the second was computerized physician order entry implementation, and the third thing was a departmental peer review,” said ACP Member Hamid R. Feiz, MD, chief quality officer and associate chief medical officer at Indian River.

Once it was underway, the initiative—specifically the peer review portion of it—pointed out an additional patient safety need. The hospital had a rapid response team, led by nurses and backed up by the emergency department, but hospital leaders concluded that it could do better. “Looking at our data and seeing response [to code blues], some of the outcomes were not to the standards that we wanted,” said Dr. Feiz. “It was recommended to add a physician, preferably a hospitalist, to the team.”

How it works

Although some hospitalists were reluctant at first (more on that later), the Indian River group agreed to take on the new responsibility. “An admitter hospitalist who does admission and consult has the code pager and responds to codes,” explained Dr. Feiz.

Hospitalists also have an active role in the new multi-disciplinary rounds, which target high-risk patients. These patients are identified as having at least one of the “seven Ps” (polypharmacy, problem medications, principal diagnosis, poor health literacy, patient support, prior hospitalization and patient safety issues) and are then visited by a team consisting of a hospitalist, nurses, a pharmacist, a nutritionist, a discharge planner and a palliative care representative. The team may assign patients to telemetry or make other recommendations to the treating physician.

“We're identifying these patients early and we're getting appropriate consultants involved,” said Dr. Feiz.

As an example, he described a recent patient who returned to the hospital with a pulmonary embolism after a valve replacement. The patient was prescribed heparin but continued deteriorating. “During our rounds, we realized that there was something wrong with the picture and we suspected heparin-induced thrombocytopenia syndrome. If this individual was kept on heparin, he would have had a very poor outcome,” Dr. Feiz said.


The multi-disciplinary team appears to have helped other patients, too. The number of code blues dropped from 23 in the first half of 2010 to 10 in the first half of 2011. Despite having the same number of rapid responses, “our codes have been the lowest in the recent years,” said Dr. Feiz.

Other improvements include an increase in the hospital's compliance with Medicare core measures, and a decrease in the average length of stay (LOS). “We believe that the multi-disciplinary team's daily round was a significant factor in reduction of LOS and improvement of core measure scores,” said Dr. Feiz.

Because several changes were made to hospital procedures at around the same time, it's difficult to separate their effects, but project leaders are not concerned. “What's unique about what we're doing here is that a lot of hospitals have rapid response teams and most of them have multi-disciplinary rounds, but we're really trying to incorporate all the changes together, because we think they all really work together,” said Elizabeth Anderson, a Florida State University medical student working on the project.


The greatest challenge in implementation came from Dr. Feiz's own colleagues. Some weren't eager to respond to codes because of the responsibility. “We have an 11-member hospitalist team. I would say it was a 60/40 split; 60% initially didn't feel comfortable doing codes,” said Dr. Feiz.

He presented the reluctant physicians with data showing that 65% to 70% of hospitalists nationwide handle codes and offered them training in advanced cardiac life support (ACLS). “They went through training, they got certified, and then we had two sessions of mock coding until they felt comfortable, and our respiratory team and our ACLS team thought that they were competent to do it,” Dr. Feiz said.

How others benefit

In addition to the improvements in processes and outcomes, Dr. Feiz thinks that the added responsibilities have been beneficial to the reputation of the hospitalists at Indian River. “They're looked at as more than a physician who does the history and physical and tucks patients in. Now they lead multi-disciplinary rounds and they lead the codes,” he said. Other programs might want to consider these benefits, especially in light of recent research questioning hospitalists' value, he added.