4/20/2011

1

Kathy Duncan, RN, Director

Christine McMullan, MPA, Faculty

April 2011

These presenters have nothing to disclose

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4/20/2011

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Early Warning Scoring Systems

Kathy Duncan, RN, Director

Christine McMullan, MPA, Faculty

April 2011

These presenters have nothing to disclose

4/20/2011

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Abbott Northwestern Hospital Minneapolis, MN

• Outcome of chart review: ─ 20 patients reviewed that had Code Blue without a RRT call within 24 hrs prior to

code:

─ Based on retrospective and concurrent chart reviews, difficult to say if medical intervention would have prevented the code or transfer to higher level of care.

─ Concurrent chart reviews of patients on pilot unit found that 39/50 (78%) of patients were in the “green zone” , 10/50 (20%) were in the “yellow” zone and 1 patient in the “orange” zone

─ Two patients that were in the “green zone” had RRT called during the shift

• Physiological Conditions that “flag” at risk patients: ─ Biggest indicators of EWSS increasing were respiratory rate and heart rate

─ UO rarely documented but when it was, it attributed to higher EWSS

EWSS Score 12 hrs 8 hrs 4 hours Time of code

0-1 7/18 pts (39%) 3/17 pts (18%) 5/18 pts (28%) 19/20 (95%)

2-3 7/18 pts (39%) 6/17 pts (35%) 4/18 pts (22%)

4-5 2/18 (11%) 5/17 (29%) 4/18 pts (22%) 1/20 (5%)

> 6 2/18 (11%) 3/17 pts (18%) 5/18 pts (28%)

Southeast Georgia Health System

• Outcome of chart review: ─ Did patients exhibit signs of medical decline prior to code

blue/transfer to higher level of care? Only 4/10 (40%)

─ Would scoring system have identified patients at risk 4hrs, 8hrs or 12 hrs prior to code blue/transfer to higher level of care? Yes. 3/10 (30%) at 4 hrs and 1/10 (10%) at 12 hrs.

─ Could medical intervention have possibly prevented the code blue/transfer to higher level of care? Yes in 3/10 (30%)

• Identify trends of physiologic conditions that appeared to flag “at risk” patients ─ The only one that seemed to impact was respiratory rate.

─ None with a difference in LOC

─ Urine output data was almost non-existence with only 2/10 (20%) with adequate information to score

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Middlesex Hospital

Middletown, CT.

• Outcome of chart review: ─ Did patients exhibit signs of medical decline prior to code

blue/transfer to higher level of care? 100% of the patients had at least a score of “1” on the MEW scale

─ Would scoring system have identified patients at risk 4hrs, 8hrs or 12 hrs prior to code blue/transfer to higher level of care? Depending on what MEW score is used as a trigger, If scale was

>1 90% of the patients would have met the trigger.

─ Could medical intervention have possibly prevented the code blue/transfer to higher level of care? With the exception of one patient perhaps.

• Identify trends of physiologic conditions that appeared to flag “at risk” patients

The most common trigger at the hours before the code was the RR breaths/min.

Early Warning Systems: The Next Level of Rapid Response Expedition

Carmen Ferrell, RN, MSN, CCRN Nancy Christiansen, RN, MSN, CCRN Soudi Bogert, RN, BSN, CCRN

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St. Joseph Hospital of Orange

525 bed, not for profit

Acute care with BHS unit

Opened 1929

Sisters of St. Joseph of Orange

Shared services to CHOC

Admits: 31,784

ALOS - Acute 3.47 days

ED: 110,200 visits

OR: 33,100 surgeries

OB: 5935 deliveries

Payer Mix

HMO 27%

Medicare 19%

PPO 19%

Capitated 18%

Medical/caid 11%

Other 6%

Early Warning System

• Early Warning System (EWS) is part of the Rapid Response System at Saint Joseph Hospital Orange (SJO)

– EWS are symptoms that identify a patient at risk for clinical deterioration

– EWS are the trigger to activate Rapid Response Team (RRT)

– The RRT at SJO is called the Medical Emergency Team (MET) which begun in May 2004

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Initial MET (Reactive) Outcomes

SJO- Code Blue by area and MET, Qtr 1 06-Qtr 1 08

30

19 2316

30

18 1422 21

21

22

28

19

1329

115

16

4

5

6

7

66

47

6

58

44

58

44

52

78

84

97 99

0

20

40

60

80

100

120

Qtr 1 CY 06 Qtr 2 CY 06 Qtr 3 CY 06 Qtr 4 CY 06 Qtr 1 CY 07 Qtr 2 CY 07 Qtr 3 CY 07 Qtr 4 CY 07 Qtr 1 CY 08

# o

f E

ven

ts

OTHER

Med / Surg

Critical Care

MET

Rapid Response Team Evolution

• From our initial results it was evident that a great deal of education on identification of early warning signs of deterioration were needed

• The EWS triggers were hardwired through education and into the paper documentation system

• RRT caused a decrease in Code events in the first 18 months but our trending down leveled off

• After review, we found EWS triggers on the flow sheet were not consistently assessed / used by the nurses

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Dedicated MET Development

• 24 Hour coverage September, 2008

• Aim to improve EWS process & compliance

• MET RN:

– Responds to “Emergent” Overheard Calls

– Available for “Consult Requests”

– Performs daily “Proactive Rounding” on pts identified as High Risk

Dedicated MET RN EWS Process

• Requested Charge RN on each floor to assist Staff RN in identifying highest acuity pts for EWS scoring

• EWS scoring education provided to med/surg areas & flyers posted

• EWS tool faxed to the MET RN each shift

• MET RN prioritized rounding based on EWS scores

• Finding: non-compliance & inconsistent reporting

• Lack of computer documentation played a part

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High Alert Report

• Created to serve as an early warning tool

• Generated from computer

• Pt list with diagnosis, and high alert labs

– Hemoglobin

– K+

– Mg+

– Troponin

– BNP

• MET RN rounds pro-actively on pts identified via report

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Outcomes- Post Dedicated Team

SJO- Code Blue by area and MET, Q3 '08- Q4 '10

17 23 28 2721 19 25

17 22 17

17 7

13 9 1711

12

8

14

4

00

14 0

0

1

2

1

0

102

66

99 100

8174

64 64

48

38

0

20

40

60

80

100

120

Qtr 3

CY 08

Qtr 4

CY 08

Qtr 1

CY 09

Qtr 2

CY 09

Qtr 3

CY 09

Qtr 4

CY 09

Qtr 1

CY 10

Qtr 2

CY 10

Qtr 3

CY 10

Qtr 4

CY 10

# o

f E

ven

ts

OTHER

Med / Surg

Critical Care

MET

Lessons Learned

• Difficult to extract early warning criteria with paper documentation

• Anticipating electronic documentation implementation August, 2011

– Built in alerts for HR, RR, BP, Temp, Urine output

– Report to be built that will pull current patient data and be available to the MET RN

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Next Steps

• We are in the process of making all the forms electronic and incorporating EWS into electronic alerts

• Pilot the EWS scoring to ensure appropriate data is being formatted into computerized documentation

• Continue to re-educate

Questions

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Repeated Use of the PDSA Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range of conditions Spread

Aim: Implement Rapid Response Team on non-

ICU unit

Improved

Communication

A P

S D

A P

S D

Cycle 1: ICU nurse responds to rapid response team calls on one unit,

one shift for one day

Cycle 2: Repeat cycle 1 for three days

Cycle 3: Have Respiratory Therapist attend

rapid response calls with ICU Nurse

Cycle 4: Expand coverage of RRT on unit

to one unit for one shift for five days

Cycle 5: Have Nurse Practitioner

respond to calls in addition to RT and

RN

Cycle 6: Expand rounds to

one unit for one shift seven

days a week

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Checking Results

• Compliance with tool

─Accuracy: Are staff accessing correctly?

─Frequency: Are staff accessing at

desired frequency?

• What actions are required as a result

of the score?

• Does the tool adequately reflect the

patient’s medical status?

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Assessing for Accuracy

25

Questions

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Pediatric Early Warning System

27

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29

3 2 1 0 Score

*

Behavior

• Lethargic,

Confused,

• or Reduced

Pain Response

• Irritable or Agitated

and Not Consolable

• Sleeping,

• Irritable and

Consolable

• Playing

• Appropriate for pt.

Cardiovascular • Grey or

• CRT ≥5 or

• Tachycardia 30

above OR

• Bradycardia for

age

• CRT 4 seconds or

• Tachycardia of 20

above normal

parameters

• Pale or

• CRT 3 Seconds

• Pink, CRT 1-2

Seconds

Respiratory

• 5 Below normal

with retractions

and/or

• ≥50% FiO2

• >20 above normal,

• using accessory

muscles or

• 40-49% FiO2 or

• ≥ 3 LPM

• >10 above normal

• Using accessory

muscles or

• 24-40% FiO2 or ≤2

LPM

• Any initiation of O2

• WNL for Age

• No Retractions

TOTAL ** Parental concern should be an automatic call to the Rapid Response Team

Pediatric Early Warning Score – PEWS

Most Critical Stable

* Add 2 points for frequent interventions (suction, positioning, O2 changes) or multiple IV attempts.

Score ≥ 7 Assmt. q 30 mins. Score 6 Assmt. every 1 hour. Score 5 Assmt. every 1-2 hours. Score 0-4 Assmt. q 4 hours

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Homework • Using MEWS

─ Utilize one of the above tools and test tool on one patient, with one

nurse and “unofficially” record results

─ Obtain feedback from nurse

* was the tool easy to use?

* how long did it take to assess the patient?

* was score an accurate reflection of patient’s medical condition?

* what medical intervention did the patient require?