using the electronic medical record for early warning · using the electronic medical record for...
TRANSCRIPT
Using the Electronic Medical
Record for Early Warning
McMaster University
Thrombosis and Atherosclerosis Research Institute
Alison Fox-Robichaud
►Present the rationale for developing an electronic EWS
►Describe the experience and outcomes at Hamilton
Health Sciences
►Discuss some of the lessons learned from this
experience.
Objectives
► Healthcare Insurance Reciprocal of Canada (HIROC) is the major insurer of hospitals in Canada
► The HIROC Top Risks in Acute Care:
▪ #2 Failure to appreciate status changes/deteriorating
▪ #5 Healthcare acquired infections
▪ #6 Inadequate triage assessment/reassessment
► In a study from Europe RNs, residents and attending staff on a medical ward did not recognize potential deterioration (Ludikhuize et al CCM 40: 2982-6, 2012).
4
Failure to Rescue is an
important health care issue
CMPA March 2014
Multiple EWS
• The earliest published was in 1997 (EWS)• Morgan et al Clin Intensive Care
• A modified version was published and validated in 2001
(MEWS). This observational study had a OR for death of 5.4
and for ICU admission of 10.9 with a score of ≥ 5.• Subbe et al Quarterly Med J
• Variations have been developed for children (BPEWS) and
with added vitals that improve the ROC (ViEWS or NEWS),
particularly with the addition of O2 sats• Parshuram et al Crit Care, 2011
• Prytherch et al Resuscitation, 2010
• Smith et al Resuscitation, 2013
The Hamilton Early Warning Score
3 2 1 0 1 2 3
HR/pulse<40 41 - 50 51 - 100 101 - 110 111 - 130 >130
Sys BP<70 71 - 90 91 - 170 171 - 200 >200
Resp Rate<8 8 - 13 14 - 20 21 - 30 >30
Temp<35 35.1 – 36.0 36.1- 37.9 38.0 - 39 ≥39.1
02 Sat<85 85-92 >92
02 TherapyRoom Air
≤5 l/minor
<50% by mask
>5 l/minor
50% by mask
Change in CNS from Baseline
CAM+ve
Alert Voice Pain Unresponsive
HEWS and ED sepsis recognition
Skitch et al. CJEM 2017
Total Cohort AUC 0.77 (0.72-0.82) Critical Event AUC 0.82 (0.75-0.90)
Supported by data from others:Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, Edelson DP. Quick Sepsis-related Organ Failure
Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in
Infected Patients outside the Intensive Care Unit. Am J Respir Crit Care Med. 2017 Apr 1;195(7):906-911.
In this cohort 47 patients meeting sepsis criteria were assigned a CTAS level of III or IV. The mean HEWS score
for these patients was 2.8 (SD=2.1), which was significantly greater than non-septic CTAS III or IV patients
(M=1.4, SD=1.7), p<0.01.
RRS Process and Our Focus
Pa
tie
nt C
on
ditio
n
Time
Detectable
Deterioration
RRT
Arrival
24 h
ours
(t)
Activa
tio
n
Cri
teri
a M
et
Population
• Cohort of all medical/surgical adult patients
at Hamilton General Hospital that had a new
RRT consult in response to clinical
deterioration between Jan 2016 – Sept 2016
• Mature RRS
– RRT with extensive training and
experience
– Electronic EWS
• Delayed activation defined as ≥ 1 hour
duration between activation criteria and rapid
response team arrival
733 Rapid
Response
Team Calls
576 Eligible
Rapid
Response
Team Calls
157 Excluded Rapid
Response Team
calls not related to
patient deterioration
435 First Rapid
Response
Team Calls
141 Recurrent
Rapid Response
Team Calls
Outcome No Delay
RRT
n (%)
Delay
RRT
n (%)
Unadjusted
Odds Ratio
(95% CI)
p Adjusted
Odds Ratio
(95% CI)a
p
ICU transfer 25 (22.9) 112 (34.4)1.76
(1.06, 2.90)0.027
1.96
(1.16, 3.32)0.012
Death 17 (15.6) 72 (22.1)1.53
(0.86, 2.74)0.148
1.57
(0.85, 2.90)0.147
Cardio-
pulmonary
Arrest 4 (3.7) 10 (3.1)
0.83
(0.26, 2.70)0.758
1.36
(0.36, 4.80)0.632
Composite
Outcome 35 (32.1) 158 (48.5)
1.99
(1.26, 3.14)<0.001
2.27
(1.39, 3.70)<0.001
RRT = rapid response teamaAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the
activation was related to HEWS ≥ 5 Call
Outcome No Delay
RRT
n (%)
Delay
RRT
n (%)
Unadjusted
Odds Ratio
(95% CI)
p Adjusted
Odds Ratio
(95% CI)a
p
ICU transfer 25 (22.9) 112 (34.4)1.76
(1.06, 2.90)0.027
1.96
(1.16, 3.32)0.012
Death 17 (15.6) 72 (22.1)1.53
(0.86, 2.74)0.148
1.57
(0.85, 2.90)0.147
Cardio-
pulmonary
Arrest 4 (3.7) 10 (3.1)
0.83
(0.26, 2.70)0.758
1.36
(0.36, 4.80)0.632
Composite
Outcome 35 (32.1) 158 (48.5)
1.99
(1.26, 3.14)<0.001
2.27
(1.39, 3.70)<0.001
RRT = rapid response teamaAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the
activation was related to HEWS ≥ 5 Call
Univariate and Adjusted OR
Duration of DelayLength of Rapid Response Team Activation Time
Outcome 1–4 Hr 4–8 Hr 8–12 Hr 12–24 Hr
ICU transfer,
Adjusted OR (95%
CI) a
1.39
(0.78, 2.55)
3.01
(1.43, 6.40)
2.59
(1.01, 6.51)
2.54
(1.35, 4.88)
Death,
Adjusted OR (95%
CI) a
1.20
(0.62, 2.39)
1.59
(0.64, 3.80)
1.7
(0.55, 4.89)
1.56
(0.75, 3.29)
Composite
Outcome,
Adjusted OR (95%
CI) a
1.73
(1.02, 3.00)
3.62
(1.76, 7.61)
2.49
(1.02, 6.13)
2.84
(1.55, 5.27)
aAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the
activation was related to HEWS ≥ 5 Call
• Smartphone App with the IBM/Thoughtwire
application with automatic calculation of the
score and integrated within Meditech.
• Three roles currently Bedside Nurse, Charge
Nurse and RACE Team. Notifications are
automatically directed to the correct role
depending on the score.
• There is no delay in reporting of patient
condition, and caregivers are aware of each
other’s status in the process.
HEWS Handheld
Lessons we are learning• All vitals signs must be mandatory
– Some allowance on temp and delirium for frequent vitals
– Aided by the electronic documentation
• Ongoing education/research is vital
– Culture change that a ward code blue can be a failure to rescue
– The impact of EMR on nursing practice needs to be evaluated
• The endpoint is not just cardiac arrest
– Composite of Cardiac arrest, unplanned ICU admission and unanticipated death
– Can facilitate EOL discussions
• The CCRT is busy…But CODE BLUE is now rare
– From 8.61/1000 admissions in FY13/14 as we started to implement
– To 4.92/1000 admissions in FY17/18
– In August we had 1 resp arrest and 1 cardiac arrest on the wards at the HGH
– All Code Blue should be audited to see if the critical event was preventable