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Hospital develops early warning system
A scoring system designed to provide an early warning of patients who may need prompt care has helped a hospital decrease its code blue calls outside the intensive care unit (ICU) by 50% and increase rapid response team (RRT) calls by 110%.
The Modified Early Warning System (MEWS) is a simple, validated physiological scoring system that identifies high-risk patients, says Janice Maupin, RN, MSN, CPHQ, director of quality and case management at Mercy Hospital Anderson in Cincinnati. The hospital began implementing the system in late 2008, because a review of code blue charts suggested that some of the cardiac arrests might have been prevented if nurses had intervened earlier.
Patients are scored on vital signs, and the higher the score, the higher the risk of mortality, Maupin says.
"We intended to pilot the program for three months, but the results were so good that we called off the pilot and went right away to implementing MEWS hospitalwide," Maupin says.
The score is calculated based on data already charted by nurses. The physiological parameters include heart rate; blood pressure; respiratory rate; temperature; and level of consciousness. Those values are measured routinely in hospitalized patients, and the score enables nurses and physicians to identify patients who are deteriorating and who need urgent intervention, Maupin explains. The MEWS score is also incorporated into existing protocols for utilizing the hospital's RRT.
The system was incorporated into the existing computer system for recording vital signs, minimizing the added work burden for nurses, Maupin says.
Director of risk management Kristin Boggs, RN, BSN, says MEWS has been a great tool for reducing the risks associated with codes and the subsequent administrative follow-up.
"That's been huge. When you have patients code in the hospital, it takes up a lot of time in terms of looking at the events, reviewing the processes, determining whether we're doing them appropriately," Boggs says. "MEWS has pretty much eliminated that for us. And from a patient safety perspective, we're just doing the right thing here. When patients do end up coding, we know that we didn't miss anything from a risk perspective."
Results good all over
The MEWS system has been used successfully in Britain and some other facilities in the United States, with users reporting significant decreases in cardiac arrests and crash team calls. A study of 2,974 patients over three years at the Royal Cornwall Hospital revealed a strong relationship between the probability of death and the MEWS score.1 OSF St. Joseph Medical Center in Illinois reported that the average number of codes per month outside the ICU decreased from 2.2 in the first 12 months to 1.3 during the last 12 months. Total codes at the facility also decreased.2 In Wales, the Ysbyty Glan Clwyd hospital decreased its crash call rate in half.
To determine how MEWS would have changed the treatment and outcome of patients, Maupin and her colleagues reviewed charts from 2007 of patients who had coded, applying the MEWS score retrospectively to the documented vital signs in the 24 hours prior to the code. They found that 60% of those patients could have possibly been identified an average of 6.6 hours earlier if the hospital had been using the scoring system at that time.
Part of the goal for MEWS is to reduce variability on when to call the RRT and to facilitate timelier nurse-physician communication, Maupin says.
"Nurses sometimes hesitate to call physicians at the first sign of deterioration, because they're just [not] sure; and they don't want to bother the physician unnecessarily," Maupin says. "We teach people that you should go ahead and call the RRT if you just feel like something isn't right. That's a valid reason to intervene, and a lot of RRTs report that that's the reason they're called in about 40% of the cases. MEWS helps people quantify when to call, but even if the MEWS score doesn't require a call, you should go ahead if something just doesn't feel right about your patient."
Prior to MEWS, the trigger for calling the RRT was based on a single parameter being so far off normal that intervention was required. For instance, a nurse would call the RRT if the heart rate was below 50, or if systolic blood pressure was above 200. With MEWs, Maupin explains, the nurse doesn't wait until one of those readings gets that severe. Rather, the combination of several readings that are bad, but not critical, can add up to a MEWS score that signals intervention.
Deterioration can be seen
At the beginning of each 12-hour shift, or more frequently as indicated, the nurses calculate MEWS scores based on vital sign parameters. The nurse can refer to the MEWS score when describing the situation to a physician, using the score as an indicator of the patient's overall condition.
Maupin provides this example: The patient has a heart rate of 112, which scores a 1. The blood pressure is 98/70, which scores a 1. The respiration rate is 18, also scoring a 1. The temperature is 100.2, which gets a score of zero. On the central nervous system measure, the patient is alert, which also gets a score of zero.
So, the patient's total MEWS score is 4. The nurse can then refer to the MEWS action instructions and see that with a score of 0-2, the nurse should continue routine and ordered monitoring. With total score of 3, the nurse should increase vital signs frequency and inform the charge nurse. At a score of 4, the nurse must inform the physician, charge nurse, and clinical administrator to assess the patient. The nurse increases vital signs frequency and pulse oximetry, closely monitors urinary output, and calls the RRT if output is less than certain levels.
With a score of 5, the nurse calls the RRT and the physician. The nurse also increases vital signs frequency and pulse oximetry. If the patient remains at a 5 score for three consecutive readings, the nurse should request an order for possible transfer to a higher level of care and consider whether an end-of-life discussion is indicated for the patient and/or family.
At a score of 6, the nurse must call the RRT and physician STAT. The nurse should recommend transfer to a higher level of care and consider end-of-life discussions.
The hospital has seen RRT calls increase 110% after implementing MEWS, going from an average of 7.8 to 16.4 calls per 1,000 patient days, Maupin says. Code blues were cut in half, from an average of 0.77 to 0.39 per 1,000 patient days.
"MEWS helps us identify patients at the earliest signs of deterioration," Maupin says. "With earlier recognition, we intervene in the best way and avoid code blues."
1. Carle C. et al. Use of a modified early warning system to predict outcome in patients admitted to a high dependency unit. Critical Care 2007, 11(Suppl 2):P479.
2. Whittington J. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Joint Commission Journal on Quality and Patient Safety 2007; 33: 9.
Janice Maupin, RN, MSN, CPHQ, Director, Quality and Case Management, Mercy Hospital Anderson, Cincinnati, OH. Telephone: (513) 624-4536. E-mail: firstname.lastname@example.org.
Kristin Boggs, RN, BSN, Director of Risk Management, Mercy Hospital Anderson, Cincinnati, OH. Telephone: (513) 624 -4059. E-mail:email@example.com.