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Why do Patients Suddenly Take Turn for the Worse?

RWJF Faculty Scholars Grant Designed to Study Cause

BOSTON - Michael D. Howell, MD, MPH, Director of Critical Care Quality at Beth Israel Deaconess Medical Center, has been accepted into the prestigious Robert Wood Johnson Foundation Physician Faculty Scholars Program, one of 20 physicians nationally and the only one in Massachusetts to participate in the program.

Howell's project, "Preventing the Need for Rescue Care: Averting Acute Inpatient Decompensations," is an extension of his work on the Triggers Program, BIDMC's model for rapid response multidisciplinary teams that quickly assess and treat potentially declining patients on the medical or surgical units. Prior to becoming unstable, patients will give off certain signals to warn their condition may be deteriorating.

His new research also focuses on inpatients in non-intensive care units. Because these patients are generally perceived to be healthier than ICU patients, they are usually monitored less closely than patients in intensive care units. However, they are still at risk for suddenly becoming critically ill. When this happens, even with programs such as Rapid Response Teams, non-ICU patients who have acute decompensations can have in-hospital mortality rates as high as 24 percent, according to some studies.

"This grant will provide substantial support over the next three academic years to develop a thoughtful, predictive approach to try to prevent acute inpatient decompensations," Howell said. "In addition to funding, the program also provides close connections to key national leaders in clinical and quality improvement research."

The $300,000 grant will fund Howell's work from July 1, 2009 until the end of June 2012. The Foundation provides funding, mentoring and dedicated time for scholars to conduct their research. Howell's project seeks to create an algorithm that will predict a patient's risk and then match that risk with an individualized system of care aimed at decreasing the number of patients who require emergent, reactive treatment.

The project's first goal is to develop a clinical prediction rule that estimates a patient's future need for emergent, reactive inpatient care. Howell will then focus on designing a system of care that will match the patient's risk as identified through the clinical prediction rule. This may include adjusting clinical care intensity through increased monitoring, more intense clinical resource allocation for sicker patients, or adjusting the nurse to patient ratio. Physicians could also be asked to make more frequent rounds, enabling earlier interventions to prevent patient decompensations.

Once a rule and system of care are developed, Howell will assess the impact of clinical implementation.

"At BIDMC, we've seen really tremendous results from our Triggers Program," Howell said. "Now, we're focusing on what's next: how to prevent the need for Triggers, and I feel exceptionally fortunate to have this opportunity over the next few years."

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and consistently ranks among the top four in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org .