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A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center

  • Original Research: Qualitative Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Recognition of clinically deteriorating hospitalized patients with activation of rapid response (RR) systems can prevent patient harm. Patients with limited English proficiency (LEP), however, experience less benefit from RR systems than do their English-speaking counterparts.

Objective

To improve outcomes among hospitalized LEP patients experiencing clinical deteriorations.

Design

Quasi-experimental pre-post design using quality improvement (QI) statistics.

Participants

All adult hospitalized non-intensive care patients with LEP who were admitted to a large academic medical center from May 2021 through March 2023 and experienced RR system activation were included in the evaluation. All patients included after May 2022 were exposed to the intervention.

Interventions

Implementation of a modified RR system for LEP patients in May 2022 that included electronic dashboard monitoring of early warning scores (EWSs) based on electronic medical record data; RR nurse initiation of consults or full RR system activation; and systematic engagement of interpreters.

Main Measures

Process of care measures included monthly rates of RR system activation, critical response nurse consultations, and disease severity scores prior to activation. Main outcomes included average post-RR system activation length of stay, escalation of care, and in-hospital mortality. Analyses used QI statistics to identify special cause variation in pre-post control charts based on monthly data aggregates.

Key Results

In total, 222 patients experienced at least one RR system activation during the study period. We saw no special cause variation for process measures, or for length of hospitalization or escalation of care. There was, however, special cause variation in mortality rates with an overall pre-post decrease in average monthly mortality from 7.42% (n = 8/107) to 6.09% (n = 7/115).

Conclusions

In this pilot study, prioritized tracking, utilization of EWS-triggered evaluations, and interpreter integration into the RR system for LEP patients were feasible to implement and showed promise for reducing post-RR system activation mortality.

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Data Availability

The data supporting the findings of this study are available upon request from the authors.

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Acknowledgements

The authors acknowledge Brittany Davis, RN, Ellenita Kornegay, RN, BSN, Jennifer Mack, MHA, MBA, BSN, RN, CCRN, Mary Jo Barfield, MBA, Kelly Reilly, MEd, the UNC Medical Center interpreters and rapid response teams, and the North Carolina Translational and Clinical Sciences Institute. In October 2023, this work was recognized as a Top Finalist for The Joint Commission and Kaiser Permanente Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity.

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Authors and Affiliations

  1. Department of Surgery, Division of Trauma and Acute Care Surgery, University of North Carolina School of Medicine, 4008 Burnett-Womack Building, Campus Box 70, Chapel Hill, NC, 27599, USA

    Lauren Raff MD

  2. Division of Hospital Medicine, Department of Medicine, University of North Carolina School of Medicine, 101 Manning Drive, Campus Box 7085, Chapel Hill, NC, 27599, USA

    Andrew G. Blank MPH, Lindsey Phillips MD, Carlton Moore MD & Evan Raff MD

  3. University of North Carolina School of Medicine, 321 South Columbia Street, Chapel Hill, NC, 27599, USA

    Ricardo Crespo Regalado & Emily Bulik-Sullivan

  4. Department of Interpreter Services, University of North Carolina Health, 101 Manning Drive, Chapel Hill, NC, 27514, USA

    Lilia Galvan Miranda

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  1. Lauren Raff MD
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Correspondence to Evan Raff MD.

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Raff, L., Blank, A.G., Crespo Regalado, R. et al. A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center. J GEN INTERN MED 39, 1103–1111 (2024). https://doi.org/10.1007/s11606-024-08678-x

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