Saved by the Nurse

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Check out this great article about nurse intuition on acuity level of patients. Link posted by Sam Ghali, MD who you should follow on Twitter. TL;DR Listen to the nurses!

The study asked nurses in 2 medical and 2 surgical units in Rochester, MN to score patients based on a 5 point “Worry Factor.” Basically deciding sick or not sick. 31,000 shifts in 3551 hospital admissions. The Worry Factor was highly accurate, with a LR of ICU transfer of 17.8 for WF>2 and LR 40.4 for WF>3. Accuracy was higher for RNs with more experience. AUROC was 0.92 for ICU transfer in 24 hours. The article specifies that they couldn’t assert whether RNs used intuition or analytical skills (something our Gut Instinct study DID try to determine).

This paper reminds me of an article I wrote a few years ago about a teaching tool for the ED, asking EM residents to decide admit vs discharge (or try to guess diagnosis, etc,) the moment they see a patient.

The references for this article are fantastic as well. Multiple primary sources and reviews on the various scores MEWS, NEWS, EWS, etc that try to identify who will decompensate in the hospital. I like to think ER nurses and doctors are especially skilled here, although we should be better about following up on patients we admit. You called the ICU and they deflected to PCU: check the chart the next couple of days, were you right or wrong? That feedback is necessary to modify your mental models and learn. At least 5 of the references cover Nurse Worry, including one systematic literature review and one prospective trial in Denmark. The references also go into intuition, expertise, they even cite the book Thinking Fast and Slow, our inspiration for the Gut Instinct abstract that was presented by Carter and Giddings.

I have had this meme in my head for a while but don’t think I ever made it or saw it on the Internet. Maybe it will go nerd viral.

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