Alerting ICU nurses to patients’ early warning scores can decrease rapid response team (RRT) calls and transfers to intensive care after a call, one hospital found. Southern New Hampshire Medical Center in Nashua saw the good results in a pilot study that implemented an “early warning score [that] was electronically embedded into medical records” and then a “communication bundle that allowed notification of and telephone collaboration between medical-surgical and intensive care nurses.”

The improvements were inspired by the experience of the brother of Cheryl Gagne, RN, DNP, NEA-BC, chief nursing officer.

As a child, her brother suffered from herpes encephalitis that eventually left him brain damaged, in part because clinicians misunderstood the illness and missed warning signs of deterioration, she says.

Gagne became interested in algorithms that were used mostly in Europe to develop early warning scores, and began looking for ways to embed them into the hospital’s electronic health record (EHR).

This was about two years before the Meaningful Use requirement, which then gave a boost to the project.

“Hospitals had to commit to creating a decision rules engine, which is programmed into the EHR. The first version had a little red exclamation mark pop up next to the patient census, but I said we had to do better than that,” Gagne recalls. “A nurse is not always carrying around a computer, so I thought we could find a way to page the nurse. The hospital found a way to do that.”

Using ICU Nurse Expertise

The goal was to catch patients before they deteriorate, she explains. This helps the individual patient but also takes pressure off of the nursing staff, which in turn yields benefits to all their patients, she says.

“With all this talk about nurses practicing at the top of their licenses, we underestimate the power of bedside nurses. ICU nurses get another level of training, have a level of expertise in some detailed areas, and respond in ways that are different from the floor nurse,” Gagne says.

“Physicians are similar in how they have different areas of expertise and they consult all the time, so I started to wonder why nurses don’t consult,” she adds. “We created a critical nurse consultation for the floors by using this early warning score in the EHR.”

The notification system alerts ICU nurses to patient deterioration that might require intervention, allowing them to either contact the floor nurse with advice or go directly to the patient, Gagne explains.

In designing the early warning system, Gagne decided to stick with a simple set of measures most familiar to nurses, rather than some of the systems she had seen used elsewhere that included dozens of sometimes obscure measures.

“I wanted to stay with the basics that nurses document regularly throughout the day — vital signs, heart rate, oxygen saturation, and so on,” she explains.

“When those numbers fall outside predetermined values, the system generates a warning alert and the ICU nurse consults with the patient’s nurse,” she says. “Or sometimes the ICU nurse will show up on the floor if it’s concerning enough, so it’s an ICU-initiated RRT as opposed to a floor-initiated RRT when the patient’s nurse goes to the bedside and determines there’s a problem.”

Fewer ICU Admissions

Twenty-one months after implementation, data analysis revealed that RRT calls overall “increased non-significantly during the study period (from 6.47 to 8.29 per 1,000 patient-days)” and that “[RRT] calls for patients with early warning scores greater than 4 declined (from 2.04 to 1.77 per 1,000 patient-days).”

Also, ICU admissions of patients “significantly declined” following RRT calls, which Gagne says suggests earlier intervention for patient deterioration. Her co-author was Susan Fetzer, RN, PhD, nurse researcher in patient care services.

“Electronic surveillance and collaboration with experienced intensive care unit nurses may improve care, control costs, and save lives. Critical care nurses have a role in coaching and guiding less experienced nurses,” the researchers concluded. (The study is available online at:

The system results in patients being assessed for concerning vital signs in minutes rather than what used to be hours in some cases, Gagne says.

“We typically see about 30 minutes before a patient gets a response from a highly qualified nurse evaluating the record and giving advice to the nurse on the floor,” she says. “The nurses field about 80% of these calls without needing to consult a physician. It helps the ICU nurses realize how important they are when they see that they can address deterioration and help these patients without having to call for a doctor.”

The early intervention does not stop every transfer to the ICU, and that is not the goal. But when patients are less sick when they arrive in the ICU, their stays are likely to be shorter.

Inexpensive Project

An early warning system of this type is relatively inexpensive to implement, at least as most hospital projects go, Gagne says.

She estimates that the project cost about $60,000 to implement. The pagers cost about $50 each, and there is a monthly $10 service fee.

“The biggest cost was for the time for the IT person to program it into the medical record. Other than that, it’s costs that you’re normally incurring, like the nurses documenting the vital signs,” Gagne says.

“It’s not a large expense to do this. And it has saved many thousands of dollars in costs from patients not being transferred to the ICU,” she adds.

The biggest challenge was convincing hospital leaders that there was value to the early warning system.

The need to show Meaningful Use helped Gagne overcome that barrier, and then she worked to build support from various areas in the hospital leadership.

“The biggest challenge when you’re talking about something with an interdisciplinary scope is getting a team from those different disciplines to work together toward the same goal,” Gagne says. “That can be a big challenge in some projects, but in this one they didn’t object much once we showed the potential benefits.”

Gagne also sees the early warning system as a step forward in better recognizing the contributions of nurses. “Nurses are ordinarily considered part of the room and board charge, but this sets them apart and could become something billable,” she says.

“As times goes on we want nursing to not be part of the bed charge, and this is certainly something that establishes some of the independent thought and actions by the nurses,” Gagne says. “We’re not creating renegades or diminishing the value of physicians, but a program like this can show the value of highly trained nurses and how they can intervene effectively with patients and improve patient care.”