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Service Delivery Innovation Profile

Early Warning Scoring System Proactively Identifies Patients at Risk of Deterioration, Leading to Fewer Cardiopulmonary Emergencies and Deaths


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Summary

Mercy Hospital Anderson nurses use the Modified Early Warning System, a simple scoring system applied to patients' routinely measured physiological vital signs to identify patients likely to deteriorate, notify physicians and other caregivers when appropriate, and take other necessary steps to avert further decline. The system has increased calls to the rapid response team, reduced "code blue" (cardiopulmonary) emergencies, and contributed (along with other hospital initiatives) to a significant reduction in mortality.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the number of "code blue" emergencies and rapid response team calls and hospital-wide mortality rates.
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Developing Organizations

Mercy Hospital Anderson
Cincinnati, OHend do

Use By Other Organizations

  • Since implementation at Mercy Hospital Anderson, MEWS has spread to the other four Mercy hospitals in southwest Ohio (Mercy Hospital Clermont, Mercy Hospital Fairfield, Mercy Hospital Mount Airy, and Mercy Hospital Western Hills).

Date First Implemented

2008
August

Problem Addressed

Many times, hospitalized patients exhibit warning signs in the hours before experiencing critical health problems (e.g., cardiopulmonary arrest), but these signs are often not recognized, leading to the patient's death (i.e., a situation commonly known as "failure to rescue"). Simple scales can often help in identifying those at risk of deterioration, but relatively few hospitals use them.
  • Missed warning signs: As many as 80 percent of hospitalized patients have physiological parameters outside normal ranges in the 24 hours before intensive care unit (ICU) admission, and up to three-fourths of such patients have at least one potentially life-threatening factor in the 8 hours before ICU admission.1 When staff fail to recognize warning signs, patients are unlikely to be transferred to the ICU, thus increasing the risk of death.2 Between 2004 and 2006, Healthgrades reported that "failure to rescue" accounted for 128 deaths out of every 1,000 patients nationally.3
  • Unrealized benefits of scoring systems: Simple scales can be used to evaluate a patient's condition quickly and to reliably predict the likelihood of deterioration (and thus the need for transfer to the ICU).4 A study of 2,974 patients over 3 years at the Royal Cornwall Hospital revealed a strong relationship between the probability of death and the Modified Early Warning System (MEWS) score.5 In Wales, after all the doctors and nurses at the Ysbyty Glan Clwyd hospital began using the MEWS score, the hospital cut the number of patient "crashes" in half.6 OSF St. Joseph Medical Center in Illinois reduced the average number of "code blues" outside the ICU substantially through use of a printed risk assessment report. Total "code blues" at the facility also fell.7 Despite these findings, many U.S. hospitals do not have such scoring systems in place.6

What They Did

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Description of the Innovative Activity

Mercy Hospital Anderson nurses use MEWS, a simple multiparameter scoring system applied to patients' routinely measured physiological vital signs, to identify patients likely to deteriorate, notify physicians and other caregivers when appropriate, and take other necessary steps to avert further decline. Key elements of the program include the following:
  • Vital sign monitoring: Floor nurses monitor patient vital signs routinely, typically once or more during each 12-hour shift. Vital signs measured include heart rate, systolic blood pressure, respiratory rate, and temperature.
  • Score for each vital sign: Floor nurses calculate the MEWS score at least once during each 12-hour shift. This score aggregates the patient's individual vital sign values into one overall score. The nurse enters the vital sign information into the electronic medical record (EMR) and then clicks on the range level for that vital sign. The system then assigns a score of 0, 1, 2, or 3 to that vital sign, as follows:
    • Heart rate: Score of 0 (50 to 100 beats per minute), 1 (41 to 50 or 101 to 110), 2 (40 or fewer or 111 to 129 ), or 3 (130 or greater)
    • Systolic blood pressure: Score of 0 (101 to 199 mm Hg), 1 (81 to 100), 2 (71 to 80 or 200 or greater), or 3 (70 or lower)
    • Respiratory rate: Score of 0 (9 to 14 breaths per minute), 1 (15 to 20), 2 (8 or fewer or 21 to 29), or 3 (30 or more)
    • Temperature: Score of 0 (95 to 101.2 degrees Fahrenheit) or 2 (less than 95 or 101.3 or higher)
    • Level of consciousness: Score of 0 (alert), 1 (responds to voice), 2 (responds to pain), or 3 (unresponsive)
  • Actions taken to prevent deterioration: The nurse calculates the total MEWS score by adding the individual scores above. By totaling the values, the risk of deterioration can be identified earlier, rather than relying on subtle changes in just one parameter. Depending on the total score, the nurse takes the following actions to prevent deterioration:
    • Total score of 0 to 2: Continue routine/ordered monitoring of vital signs.
    • Score of 3: The nurse increases vital sign monitoring frequency to 2-hour intervals and calculates the MEWS score each time. If the patient remains at "3" for three consecutive readings, the nurse calls the clinical administrator to assess the patient (see bullet below for more information on this assessment).
    • Score of 4: The nurse informs the patient's physician, charge nurse, and clinical administrator of the elevated score. The clinical administrator assesses the patient. The nurse increases vital sign monitoring frequency to 2-hour intervals and calculates the MEWS score each time. The nurse also measures fluid input and output and notifies the clinical administrator if urine output falls below 100 cc every 4 hours.
    • Score of 5: The nurse calls the rapid response team and informs the patient's physician of the score. The nurse increases the frequency of vital sign monitoring, including pulse oximetry, to hourly. If the patient remains at "5" for three consecutive readings, the nurse requests a physician's order for possible transfer to a higher level of care (typically the ICU).
    • Score of 6 or greater: The nurse calls the rapid response team and the patient's physician immediately. Typically, patients with a score of "6" or greater are immediately transferred to a higher level of care.
  • Clinical administrator assessment: The clinical administrator, an experienced, advanced cardiac life support–certified nurse or nurse manager, assesses patients with high MEWS scores, as outlined below:
    • Responding to floor nurse notification of elevated score: When the floor nurse calls to report a MEWS score of 3 or greater, the clinical administrator assesses the patient and implements appropriate interventions using 1 of approximately 10 algorithms for treating a particular symptom. For example, if the patient is hypotensive (abnormally low blood pressure), the administrator considers interventions such as increasing fluids and calling the rapid response team.
    • Proactive monitoring of at-risk patients: Twice daily, the clinical administrator receives a list of all patients with a MEWS score of 3 or greater; this report is printed automatically by the hospital's EMR. The clinical administrator proactively checks on these patients during rounds, monitors them for possible deterioration, and communicates with the floor nurse for status updates.
  • Debriefings: The clinical administrator responds to every "code blue" emergency and, at the end of the code, gathers the clinicians involved to review the event; determines what, if anything, could have been done differently; discusses MEWS score use; and assesses teamwork and communication.
  • Ongoing chart reviews to facilitate improvement: A performance improvement coordinator in the hospital's Quality Services Department performs a chart review of all "code blues" to determine whether the code could have been avoided. The coordinator reviews vital signs, calculates MEWS scores, and confirms that the scoring system was used properly.

Context of the Innovation

Mercy Hospital Anderson is a 200-bed, suburban, acute care hospital serving the eastern suburbs of Cincinnati, OH. In early 2008, the hospital completed a common cause analysis of 2006 to 2007 sentinel event mortalities and found "failure to rescue" to be a root cause in 30 percent of deaths. Further analysis of these identified cases revealed that 60 percent of patients showed deterioration of vital signs and signs of restlessness or other indicators of decline well before the "code blue" event. Nurses' notes typically documented the objective information, as well as the fact that the physician had been informed of sporadic pieces of information, but there was no indication that the nurses assimilated all factors into a cogent presentation for the physician. Key stakeholders agreed that the hospital needed a mechanism or process to assure earlier recognition of patient decline, offer the nursing staff guidance for increased patient surveillance, and provide more objective, comprehensive information to trigger rapid response team calls.

Did It Work?

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Results

The use of MEWS at Mercy Hospital Anderson has reduced "code blue" calls; increased calls to the rapid response team; and, along with other initiatives, contributed to a significant reduction in hospital-wide mortality.
  • Fewer "code blue" calls: During the trial phase (June 7 to August 5, 2008), the pilot unit experienced no "code blue" calls. Since hospital-wide expansion in August 2008, "code blue" calls per 1,000 patient days fell from 0.72 (during the August 2007 to February 2008 period) to 0.33 (between August 2008 and February 2009). Since hospital-wide expansion, only three "code blue" calls have occurred on all medical/surgical/telemetry units combined. A review of these three codes indicated that one was a sudden arrest with no precipitating signs (and therefore could not have been prevented), one could have been prevented if the MEWS score had been calculated appropriately, and one occurred even though the patient was properly assessed with MEWS and appropriate actions were taken before the "code blue."
  • More response team calls: During the trial phase, the pilot unit experienced a sharp increase in rapid response team calls. Since hospital-wide expansion, rapid response team calls have more than doubled, from 2.2 to 4.8 per 1,000 patient days.
  • Contributed to overall decline in mortality: MEWS is one of several hospital initiatives that have contributed to a decline in the hospital-wide mortality rate, which fell from approximately 2 percent in 2007 (before MEWS implementation) to 0.6 percent in November 2008.
  • More confident nurses: Anecdotal reports from nurses (especially those with less than 5 years' experience) suggest they feel more confident when contacting a physician about a patient, as they now have objective data on which to base their concerns.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including the number of "code blue" emergencies and rapid response team calls and hospital-wide mortality rates.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Team formation: The hospital formed a team to identify and implement process improvements to reduce "failure to rescue." Team members included the vice president of medical affairs, director of quality and case management, nursing leadership, clinical administrators, and staff nurses.
  • Baseline analysis: The team reviewed the current criteria for calling the rapid response team. The team also surveyed 20 nurses on a medical/oncology unit and found that 75 percent of those with less than 5 years experience felt confident "only occasionally" in their assessment skills when calling physicians.
  • Literature review: The team conducted a literature review on "failure to rescue" and discovered that many hospitals in the United Kingdom and a handful of early adopters in the United States used MEWS.
  • Retrospective chart review: The team conducted a retrospective chart review of the hospital's 23 "code blues" in 2007 on the medical/surgical/telemetry units. The MEWS score was retrospectively applied to vital signs in the 24 hours before the code call. The team found that in 60 percent of the cases, recognition of deterioration would have been picked up within an average of 6.6 hours before the code (ranging from 3 to 26 hours) if MEWS had been used.
  • Pilot test: In June 2008, a scheduled 3-month pilot of MEWS began on a medical/oncology unit. The team branded the project with an identifiable logo and ordered T-shirts with this logo to begin promotion. The team also created educational tools for staff, while an information technology professional built the MEWS tool into the hospital's vital sign documentation module of the EMR. Four registered nurses on the unit received training and then met individually with each of their coworkers to review the project, demonstrate MEWS, and answer questions. The pilot began on June 7, 2008. The four registered nurses were scheduled so that there was at least one of them working at all times during the first week. In addition, the performance improvement coordinator and quality director made daily rounds during the pilot to coach and educate staff.
  • Earlier-than-expected system-wide expansion: Nurses in the float pool learned to use the MEWS tool while working on the pilot unit and then described the tool to colleagues on other units. Eventually, nurses began using the tool on their own outside the pilot unit. In fact, it spread so quickly that the pilot was shortened to 2 months, and the program spread hospital-wide (to all medical/surgical/telemetry units) on August 5, 2008, a month earlier than planned. Hospital-wide education occurred in the same train-the-trainer manner as described for the pilot unit. As of July 2009, the hospital plans to expand the MEWS tool to the emergency department, where emergency department nurses will calculate a MEWS score within 30 minutes of the patient being transferred to a floor unit; if a patient's score is "4" or higher, the transfer will be stopped and the patient reassessed for a possible change in the level of care at admission.

Resources Used and Skills Needed

  • Staffing: The ongoing operation of the program requires no additional staffing, as nurses incorporate it into their daily routines. Information technology personnel worked approximately 30 hours to create the scoring system within the EMR. The performance improvement coordinator devoted approximately 5 hours per week for the first 3 months to assure compliance.
  • Costs: The program costs little if anything to operate on a daily basis. As noted, development costs consisted primarily of staff time.
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Funding Sources

Mercy Hospital Anderson
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Adoption Considerations

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Getting Started with This Innovation

  • Embed assessment system into workflow: To ensure compliance, incorporate the scoring system seamlessly into nurses' daily routines so that it does not seem like an additional burden. Ideally, calculation of the MEWS score should be automated to the extent possible.
  • Address staff resistance: Nurses on the pilot unit initially resisted use of the tool, largely due to concerns about time limitations. However, one-on-one coaching convinced each nurse to try it one time. When they did, they all reported the tool to be easy to use, requiring only an extra few seconds. Coaches and nurses discussed how the possibility of saving a patient's life made spending these extra few seconds worthwhile.

Sustaining This Innovation

  • Provide ongoing feedback and reward use and success: Providing frequent feedback to staff on the effectiveness of the MEWS tool and holding debriefings after each "code blue" can help sustain nurses' interest in using the tool. At Mercy Hospital Anderson, nurses on the pilot unit received weekly feedback regarding compliance with the tool and statistics regarding "code blues" and rapid response team calls. Individual nurses received public recognition for their use of the tool, while success stories regarding "good catches" were shared. After 1 month without any "code blues" on the unit and an increase in use of the rapid response team, unit nurses celebrated their success at a special luncheon.
  • Continue coaching: Continue coaching the nursing staff to ensure appropriate use of the tool.

Use By Other Organizations

  • Since implementation at Mercy Hospital Anderson, MEWS has spread to the other four Mercy hospitals in southwest Ohio (Mercy Hospital Clermont, Mercy Hospital Fairfield, Mercy Hospital Mount Airy, and Mercy Hospital Western Hills).

Additional Considerations

  • MEWS facilitates early recognition of a gradual decline in health status that, if not managed, can lead to death. However, it cannot eliminate all "code blue" events, as some may occur without warning. For example, sudden cardiopulmonary death can be caused by a number of events, such as the rupture of an aortic aneurysm, that cannot be predicted or prevented.

More Information

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Contact the Innovator

Janice M. Maupin, RN, MSN, CPHQ
Director, Quality Services
Mercy Hospital Anderson
7500 State Rd
Cincinnati, OH 45255
(513) 624-4536
E-mail: jmmaupin@health-partners.org

Innovator Disclosures

Ms. Maupin has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Carle C, Pritchard C, Northey S, 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. Available at: http://ccforum.com/content/11/S2/P479

Institute for Healthcare Improvement. Early warning systems: scorecards that save lives. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/EarlyWarningSystemsScorecardsThatSaveLives.aspx

Cuthbertson BH, Boroujerdi M, McKie L, et al. Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient? Crit Care Med. 2007;35(2):402-9. [PubMed]

Footnotes

1 Tarassenko L, Hann A, Young D. Integrated monitoring and analysis for early warning of patient deterioration. Br J Anaesth. 2006;97:64-68. [PubMed] Available at: http://bja.oxfordjournals.org/cgi/reprint/ael113v1
2 Franklin C, Mathew J. Developing strategies to prevent in hospital cardiac arrest: analyzing responses of physicians and nurses in hours before the event. Crit Care Med. 1994;22:244-7. [PubMed]
3 Fifth annual Healthgrades patient safety in American hospitals study. April 2008. Available at: http://www.healthgrades.com/media/dms/pdf/PatientSafetyInAmericanHospitalsStudy2008.pdf
4 Cuthbertson BH, Boroujerdi M, McKie L, et al. Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient? Crit Care Med. 2007 Feb;35(2):402-9. [PubMed]
5 Carle C, Pritchard C, Northey S, 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. Available at: http://ccforum.com/content/11/S2/P479
6 Institute for Healthcare Improvement. Early warning systems: scorecards that save lives. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/EarlyWarningSystemsScorecardsThatSaveLives.aspx
7 Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient Saf. 2007;33(9):569-74. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 23, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 15, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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