Welcome to the latest installment of the AMSN Digital Content Committee (DCC) interview series. This interview marks the last with session presenters from the 2024 AMSN Convention, but stay tuned for the DCC’s deep dive into sessions from the 2025 AMSN Convention. Here, Anthodith M. Garganera, MSN, MHA, RN, CNL, CMSRN, a member of the DCC, talks with Matt Bemer, BSN, RN, CCRN, about his session, “Failure Is Not an Option: Assessment Strategies to Identify Patients at Risk of Deterioration.”

Anthodith M. Garganera: This is a very thorough presentation. One of the slides that caught my attention was the Triangle Assessment. I follow a lot of cases in my hospital, and sometimes we miss looking at the skin perfusion itself. I think the more you see patients, sometimes you miss that there's already something going on that's changing. Can you tell us more about the Triangle Assessment? Was there an evidence-based study or research?

Matt Bemer: I sometimes work as a rapid response nurse. Many times when I get a call, I’ll ask, “How long has the patient been this way?” And I can tell by looking into their eyes that they really haven’t seen this patient, though it's five hours into the shift. I was looking for ways to make quick contact and get basic information right away. When I became a rapid response nurse, people would say every call is different, and you just have to be ready for everything. I prefer having standardized ways of doing things. A game changer for me was recognizing that PALS (Pediatric Advanced Life Support), which includes the Pediatric Assessment Triangle, applies to adults. These are good, basic assessment skills.

When I was preparing my presentation, I looked for a similar evidence-based assessment geared toward adults. I came upon a podcast about the European Trauma Course, which has something similar to the pediatric assessment triangle called an “assessment triangle.” The three legs of the triangle aren’t any different, but it helped me adapt the concept for adult practice and make it as easy as possible to digest. You are assessing the patient very quickly from across the room. The assessment consists of three parts: Social Interaction, Respiratory Effort, and Skin Perfusion. By quickly assessing the patient’s level of arousal, work of breathing, and skin color, you get a general understanding of how well they are perfusing.

Garganera: Not every patient is attached to a monitor, so having this assessment triangle is something to look at closely. I also was interested in the AVPU (Alert, Verbal, Painful, Unresponsive) Scale. Is this used to assess the patient’s response level?

Bemer: The AVPU Scale is what you see in the trauma nurse core curriculum, which is the paramedic school for nurses, so to speak. It’s from ATLS (Advanced Trauma Life Support), which is a trauma assessment protocol.

The point is that you need to do a quick assessment of each patient during the first 15 minutes of your assignment to see what’s going on. It could be very helpful if things were to change later in your shift.

Garganera: Another critical patient assessment in your presentation is “The Needy Nine.” Thank you for highlighting these nine assessments that nurses should perform. Is this the one that nurses discuss with you during rapid responses?

Bemer: In a perfect world. A diagnosis of wellness is a diagnosis of exclusion. If any of the nine things are wrong, you need to look at all nine of them, all the time. It’s been my experience that people will let certain irregularities slip by, like with blood pressure, for instance, recycling the cuff to get the number right. The point is to focus attention back to the fact that something might be wrong with the patient, and you can’t say for sure until you’ve proven it by looking at all these things every time there’s any clinical suspicion of an abnormality.

Garganera: Do you look at the trends also? How far do you go back when you look at “The Needy Nine?” Do you go back a certain period of time as a trend?

Bemer: As a rapid response, no. But when I had bedside assignments, I would always check the electronic health record (EHR) to view patients’ vital signs over the previous 12 hours. We analyze all the metrics on a monthly basis, and you’ll see that patients may have met the criteria for a rapid response and may not have been activated. Unfortunately, it’s a constant battle; we know we can’t activate every time. For instance, a patient may have a heart rate of 20 for a few days, but you can’t be calling every two seconds. However, you have to keep everyone at every level involved. It helps to have an extra set of eyes on the data because interventions occur faster, and from a liability standpoint, you can say, “Hey, I noticed this. I did my part. If something else happened, it wasn’t for a lack of trying on my end.”

At my institute, it’s something we’re trying to enforce: You come on shift, a patient meets the criteria, and you activate for a rapid response, regardless of what’s been activated already. Then what you’ve done is put the onus on the rapid response team to decide how to proceed. But again, the data is only as good as what’s been input. At some hospitals in our system, the patient’s vital signs are automatically uploaded into the EHR from the machine, but that’s not always the case. If a nursing care assistant is collecting vital signs and then inputting them into the EHR a considerable amount of time after they were taken, you might be expecting to look at the eight o’clock vitals, but they don’t show up in the system until 10 o’clock, and you might not see them until 11 o'clock because you’re busy doing everything else. These early systems aren't always as helpful as they could be in an optimized situation.

Part of the impetus for my presentation was a study in Critical Care Nurse showing that focused assessments can result in a decrease in incidents. The evidence supports that some assessment and continuing education results in benefits down the road.

Garganera: We also look at staffing and patient ratios, which can affect patient outcomes.

Bemer: When I do my rounds as a rapid response nurse, I can see a look in people’s eyes that lets you know what’s going on and how stretched thin they are. It’s challenging because, at least in my hospital system, the patients have never been sicker. The acuity is higher at all levels of care. The ratios are less than ideal, but I notice primarily in general medicine but even in critical care the amount of contract nurses from outside the enterprise who bring a large variety of skill sets. Sometimes you’re not only doing your assignment, but you’re also helping someone who’s been assigned six to eight patients and might not be up for the task. Everyone is stretched.

Garganera: Of all the cases you’ve handled as a rapid response nurse, is there any diagnosis that stands out in terms of a negative outcome?

Bemer: I work at the Cleveland Clinic’s main campus, which is known for its cardiac surgery. We have a couple rapid response teams, and I work with the cardiac medical emergency team. The patients I treat primarily have had some sort of thoracic surgery, or they’ve been in the cardiac care unit and are now in a cardiac step down, so there’s a variety. My patient mix is probably 70% cardiac issues, but there’s a lot of lung transplant patients as well.

A rapid response is called because the patient has begun to decompensate in some way. At that point, many of the interventions are aimed at improving the patient’s hemodynamics and oxygenation/ventilation. These interventions are initiated regardless of the patient’s original diagnosis. I would argue that it is the lack of recognition that the patient is decompensating is the biggest factor in terms of negative outcomes. That is why I feel these assessment strategies are so important.

Garganera: You also mentioned in your presentation that hypotension is a late sign of shock. Could you share more about that?

Bemer: Going back to the early warning systems, by the time the blood pressure is low, the cat’s out of the bag, so to speak. If you’re checking whether the skin is cold, whether there’s a delayed capillary refill, performing a physical assessment, sometimes those subtle changes will appear considerably earlier. If you’re waiting to see a decrease in the blood pressure, we probably could have intervened earlier had someone noticed that.

Again, it’s about trying to focus attention on all the information that a quick bedside assessment can give you. I know many nurses are already overwhelmed, and it sounds like there’s no time to do another test, but during the presentation, I performed a mock bedside assessment to show that it takes just minutes. It really doesn’t take a long time. If you set aside three minutes per patient in the first half hour of your shift, you've got that baseline, and then as you're passing meds or giving baths or whatever you're going to do that day, you have a chance to reassess at that time with another extra minute of your time. There’s your opportunity to see some subtle changes that wouldn't be picked up otherwise. If you're waiting for a respiratory rate of 30 or now the blood pressure has gone down, I think there's been ample time in between that could have been used to intervene. It’s an ounce of prevention.

Garganera: With patients who are diagnosed with sepsis as an inpatient, I have noticed that they often don’t have good outcomes. I asked about hypotension because I think that this is something we also need to look at with our sepsis population.

Bemer: That's a challenging diagnosis, right? Statistically, the odds are less and less in your favor as more and more goes wrong. So, despite all the high-quality care, you have not-so-great outcomes. That’s why you’re trying to recognize these things as early as possible to give patients the best possible chance.

Garganera: Is there anything else you’d like to add?

Bemer: I just think it’s important to note that these are easy skills that are within anyone’s reach, and I was able, with very little work, to find some good quality evidence that it leads to positive outcomes. I live my life, as far as my career, according to the concept of “the basics done right.” I think these are just basic skills that are neglected due to the amount of work that nurses have, and it’s my job to bring them back to the forefront. It’s a small investment of time, and by the time I’m involved in the situation, things have turned bad. I’ll ask the bedside nurse whether the patient’s pupils have always been this way, and they’ll have to own up to the fact that they’re unsure. That’s a terrible spot to be in, and it hurts me for anyone to be in that position. I’m just trying to reinforce the point that a small investment of time earlier could prevent such situations.

Just be suspicious. Assume everyone’s sick until proven otherwise. That change in mindset is very helpful in identifying what your next step should be. Because shifts go a certain way more often than not, you could become lax, but it’s our job as providers to ensure we’re acutely aware that we’re dealing with people who are in a hospital and are unwell.

Garganera: Lastly, could you speak about any feedback you received at the convention about your session?

Bemer: I'm not a public speaker. I did this to stretch myself. My belief is that the message is important, and it doesn’t matter who’s saying it, even someone like me. Coming back to my own institution, I've been able to present the same presentation on a smaller scale. You try to advocate for the patients in any way you can, and this is just one way that I've been lucky enough to be able to do it.