Improving patient safety and care quality using a Modified Early Warning Scoring System (MEWS) on an inpatient cardiac medicine unit

Holly Andrews RN; Jean Carne RN, MScN; Andrea Fong RN, BSN, CCN(C); Jenny Knoll, RN BSN; Christopher Talusan RN, BSN and Robert H Boone, MSc MD FRCPC

5A – Heart Centre St. Paul5A – Heart Centre St. Paul’’s Hospitals Hospital

• Referral center for British Columbia’s most acute cardiac patients.

• Cares for many complex cardiac patients who have an increased risk of experiencing adverse events.

• Prior to implementing the MEWS system our cardiac medicine unit (5A) had one of the highest numbers of code blue responses in the hospital (excluding Critical Care).

5A Code Data – Before MEWS5A Code Data – Before MEWS

Data provided by SPH Code team

• A simple tool to help nurses detect early deterioration of patients.

• Subtle changes may be apparent up to 8 -12 hours prior to an adverse event.

• A score is generated based on 5 physiological parameters:

– blood pressure (BP)

– heart rate (HR)

– respiratory rate (RR)

– temperature (T)

– level of consciousness (LOC)

The specific goals of implementing MEWS were:

1. Patient Safety

2. More efficient transfer of unstable patients to critical care

3. More timely physician interventions

4. Decreased number of code blues

5. Improved communication between nurses and physicians

• Registered Nurses

– One from each rotation

• Clinical Nurse Leader

• Clinical Educator

• Physician

• Operational Leader

• Institute for Health Care Improvement sponsored 6 webinar series

– a total of 274 people attended from international centres

• 2+ month period

• Tests of changes included:

– Code blue chart audits

– Determining tool’s ease of use

– Development of tool to meet our patient population

– Tool validation

– Confirming tool accuracy of patient condition

– Algorithm development for use with tool

• Nurse found the tool easy to use and reliable to trend patients condition.

Modifier: For non surgical pain please add the following to your MEWS score:

Green = 0 – 1 Yellow = 2 – 3 Orange = 4 – 5 Red = ≥ 6

Modified Early Warning System (MEWS) - 5A 3 2 1 0 1 2 3

Resp rate per minute

Less than 8 9-17 18-20 21-29 More than 30

Heart rate per minute

Less than 40 40-50 51-100 101-110 111-129 More than 130

Systolic blood pressure

Less than 70 71-80 81-100 101-159 160-199 200-220 More than 220

Conscious Level (AVPU)

Unresponsive Responds to pain

Responds to voice

Alert Agitation or confusion

New onset of agitation or confusion

Temperature Less than 35.0 35.1-36 36.1-38 38.1-38.5 More than 38.6

Ongoing pain unrelieved with intervention ADD 3 points

Pain relieved with intervention but pain returns within 2 – 4 hours ADD 2 points

Pain relieved with intervention but pain returns within 8 hours ADD 1 point

Color Action

0-1 Green Rescore with VS as per protocol

2-3 Yellow Ensure accuracy and significance of findings

Investigate cause and treat appropriately

Notify Charge Nurse

RN reassesses and rescores in 4 - 6 hrs (use clinical judgment)

Notify MRP if patient scores 3 in any one single category4-5 Orange Ensure accuracy and significance of findings

Investigate cause and treat appropriately

Notify MRP

Notify Charge Nurse

Page Clinical Resource Nurse

RN monitors and rescores q1hr until improvement in patient’s condition

-if no improvement after 2 hrs, notify MRP for reassessment and plan

-5A CN to notify Critical Care CN of patients condit ion

When stable reassess and rescore depending on most recent score6+ Red Ensure accuracy and significance of findings

Investigate cause and treat appropriately

Notify MRP

Notify Charge Nurse – CN to notify Critical Care CN of patients condition

Page Clinical Resource Nurse

RN monitors and rescores q15 minutes until improvement in patient ’s condit ion

-if no improvement after 1 hrs, notify MRP for reassessment and plan

Key Features:

– Clear expectations

– Physician response times

– Communication plan

• 1:1 teaching sessions to each RN

• Daily follow-up and support

• Medical orientation and support

• Completed with each set of VS

• Recorded on daily charting record

• Elevated MEWS score: Orange / Red are added to patient care board

Arrests Arrests

Data provided by SPH Code team

Codes Codes

Data provided by SPH Code team

RED MEWS

Orange MEWSOrange MEWS

• Mews works for our patient population

• No adverse impact on RN workload

• No adverse impact on Physician workload

• More efficient transfer of unstable patients to critical care

• More timely physician interventions

• Improved communication

• Nursing and Physician

• Charge Nurse to Charge Nurse

Thank youThank you

Contact us:

•handrews@providencehealth.bc.ca

•Jcarne@providencehealth.bc.ca

Articles– Morgan, RJM, et al. An Early Warning Scoring System for

detecting developing critical illness. Clin Intens Care 1997; 8:100

– Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward [Abstract] Br J Anaesth. 1999;84:663P