Rothman: Beyond the Early Warning Score, The Rothman Index

Clinical Pearls (assisted by Lia Losonczy, MD MPH)

Bottom line:

• The Rothman Index is a composite number based on:
  • Key nursing assessments
  • Vital signs
  • Laboratory values
• Helps predict the patient’s risk of death
• The trend of this score helps identify patients who are at high risk of decompensating
• Validated by 24 peer-reviewed articles, 33 conference presentations, and numerous ongoing studies!
  • 8300 times cited!

The Rothman Index Model:

• Heart of Model is 3 pronged:
  • Nursing Assessment
    • All nurses make assessments of patients by system
    • These assessments have binary value: either they meet or do not meet the standard for that assessment
      • Example: GI system standard requirement would be that the patient has a soft, non tender abdomen, with present bowel sounds present, no nausea or vomiting, no incontinence
        • Must ALL to be true that met the standard
        • If one is not met, did not meet standard.
      • Assessments are recorded at least twice a day
    • All hospitals record essentially the same data, but in different ways
      • Rothman standardizes the reporting between hospitals so it can be compared
    • Early findings:
      • Nursing assessments serve as early indicators of decompensation even when patient maintains normal vital signs
        • Confusion, dietary changes, development of edema
      • Ex: patients are 9.4 times more likely to die in hospital with a failed neuro assessment
  • Estimation of Risk
    • Abnormal values of certain lab tests and vital signs predicted risk of mortality
    • Using population norm estimates, the Rothman Index is able to identify both normal values and escalation of risk with data trends
      • Ie: more deviation from normal leads to an escalation of mortality risk

• Common Scale (Data Fusion)
  • Each variable in the index can be charted to an excess risk curve (see above)
    • Greatest impact: Food/Nutrition
  • Created a way to codify each patient’s risk of death from all of these metrics
  • Sum risk over total number of variables (26 possible)
    • Normal = no risk = 100
      • Lower the score, the sicker the patient

How to use and interpret the Index score:

• This Index was built to capture the concept of risk
  • Validated at 3 different hospitals to predict risk of 24 hour mortality
    • Better predictor of mortality compared to Apache III
  • Has also been validated to predict 30 day risk of readmission
  • Correlates with both length of stay and cost of stay
• Follow trends for predictions:
  • Very High Acuity rule
    • Has the patient’s score been below 20?
      • If yes, mortality risk 25.9% if no, 0.3%
        • This rule captures 86% of deaths
      • Patients who trigger the Very High Acuity Rule, they are 80 times more likely to expire in the hospital
  • High Acuity Rule
    • Index falls 50% within 24 hours: risk of mortality is 16.6%
  • Medium Acuity Rule
    • Index falls 30% within 6 hours: risk of mortality is 10%
• Other uses:
  • Earlier identify people appropriate for palliative care consult
  • Measure current hospital admission score against previous admissions
  • Graph a patient’s overall trajectory
    • Assist to triage patients who are appropriate to leave the ICU
    • Can help predict readmission to an ICU
  • Prioritize who should be rounded on/triaged first
    • Can decrease mortality by up to 30% in multiple studies, especially related to sepsis!

Overall, can be utilized to prioritize your attention!