Use the MEWS: Help Keep Our Patients Safe Rita Borrett, RN, BSN, CMSRN Nurse Manager, 3 Surgical...

Use the MEWS:Use the MEWS: Help Keep Our Patients Safe Help Keep Our Patients Safe

Rita Borrett, RN, BSN, CMSRNRita Borrett, RN, BSN, CMSRNNurse Manager, 3 SurgicalNurse Manager, 3 Surgical

Elisia Heidt-Penrod, RN, BSNElisia Heidt-Penrod, RN, BSNNurse Manager, 4 OrthoNurse Manager, 4 Ortho

IntroductionIntroduction

Dr. Jeff CrandallDr. Jeff Crandall

Medical Director of Clinical Medical Director of Clinical InitiativesInitiatives

Iowa Health SystemIowa Health System

Code Buster A3Code Buster A3

Why We StartedWhy We Started

Number of Code Blues Outside of Number of Code Blues Outside of ICUICU

Multidisciplinary Critical Care Committee Multidisciplinary Critical Care Committee Medical Emergency Team (MET) Medical Emergency Team (MET)

Rapid Response TeamRapid Response Team

Code Blues outside of the ICU Code Blues outside of the ICU continuecontinue

Lack of vital signs within the few hours Lack of vital signs within the few hours leading up to cardiopulmonary arrestleading up to cardiopulmonary arrest

Number of MET calls/1000 Number of MET calls/1000 discharges vs. Number of Code discharges vs. Number of Code Blues/1000 dischargesBlues/1000 discharges

0

5

10

15

20

25

30

35

AprilM

ayJu

neJu

ly

August

Sept

MET calls

Code Blue

Number of MET calls vs. Number of Number of MET calls vs. Number of Code Blues outside of ICU/Cath labCode Blues outside of ICU/Cath lab

0

5

10

15

20

25

30

35

April June August

MET calls

Code Blue

Calls to the METCalls to the MET

Calls are generally triggered:Calls are generally triggered:one very abnormal vital signone very abnormal vital sign

worry about the patientworry about the patient

Average of 22 calls/month in 2009Average of 22 calls/month in 2009



Allen’s Criteria for Calling METAllen’s Criteria for Calling MET

Allen’s MET CriteriaAllen’s MET Criteria

MET calls triggered by isolated MET calls triggered by isolated criteria that are extremely abnormalcriteria that are extremely abnormal

May not identify some of the more May not identify some of the more subtlesubtle signs indicating deteriorationsigns indicating deterioration

May not identify deterioration at an early May not identify deterioration at an early stagestage

Better identification pre-code…Better identification pre-code…

Would Would scoringscoring multiplemultiple criteria help to criteria help to identify patients with subtle warning identify patients with subtle warning signs earlier?signs earlier?

Modified Early Warning Scoring Modified Early Warning Scoring System (MEWS) System (MEWS)

Examines multiple criteriaExamines multiple criteria

Aggregate scoring of multiple criteriaAggregate scoring of multiple criteria

What the Literature SaysWhat the Literature SaysModified Early Warning Scores (MEWS)Modified Early Warning Scores (MEWS)(1,2)(1,2)

RespirationsRespirations

Heart RateHeart Rate

Systolic B/PSystolic B/P

Level of ConsciousnessLevel of Consciousness

TemperatureTemperature

Additional assessments as score increasesAdditional assessments as score increases

Urine outputUrine output

O2 SaturationO2 Saturation

What the Literature SaysWhat the Literature Says

Value of rapid response teamsValue of rapid response teamsHelp to decrease incidence of cardiac arrests by Help to decrease incidence of cardiac arrests by responding rapidlyresponding rapidly (1) (1)

Earlier recognition results in earlier assistanceEarlier recognition results in earlier assistance

Problem: when to contact the rapid response Problem: when to contact the rapid response team?team?

Usually contacted with significant change in vital Usually contacted with significant change in vital signs or “something isn’t quite right” with the signs or “something isn’t quite right” with the patientpatient(1)(1)

But, could improve response if contacted BEFORE But, could improve response if contacted BEFORE a significant change in vital signs occurreda significant change in vital signs occurred


Early Warning Scoring System (EWS)Early Warning Scoring System (EWS)(4,6)(4,6)

Designed to identify subtle vital sign changes Designed to identify subtle vital sign changes earlier in surgical patientsearlier in surgical patients

Scores multiple criteriaScores multiple criteria

Updated to Modified Early Warning System Updated to Modified Early Warning System (MEWS)(MEWS)(4)(4)

Further potential for identifying other (e.g., Further potential for identifying other (e.g., medical) patients who were at riskmedical) patients who were at risk

Added O2 sat and urine outputAdded O2 sat and urine output

Quantifies criteria into a single score that Quantifies criteria into a single score that triggers interventiontriggers intervention

MEWSMEWS

Modified Early Warning Scoring Modified Early Warning Scoring System helps to identify signs of System helps to identify signs of deterioration earlier deterioration earlier (3)(3)

Earlier recognition leads to fewer Earlier recognition leads to fewer codes codes (3)(3)

Not a great deal of research support,Not a great deal of research support,But benefits dramatically outweigh But benefits dramatically outweigh burdens…burdens…


MEWS helps to identify patients at MEWS helps to identify patients at risk for deterioration sooner and save risk for deterioration sooner and save lives!lives!

Decreased cardiac arrests/code blue Decreased cardiac arrests/code blue calls calls (1,3,4)(1,3,4)

Increased MET calls Increased MET calls (1,2,3(1,2,3) )

Decreased unexpected deaths Decreased unexpected deaths (2,4,5)(2,4,5)

Decreased unplanned admission to ICU Decreased unplanned admission to ICU (2,5)(2,5)


MEWS empowers nursesMEWS empowers nurses(3)(3) to know to know when to:when to:

continue monitoring and routine carecontinue monitoring and routine care

increase monitoring of VS and when to increase monitoring of VS and when to inform others of subtle changesinform others of subtle changes

notify the physiciannotify the physician

contact the MET teamcontact the MET team

How We StartedHow We Started

A3 done by Dr. Crandall in June 2010 A3 done by Dr. Crandall in June 2010 which proposed use of MEWS which proposed use of MEWS

Development of MEWS form for Allen Development of MEWS form for Allen HospitalHospital

For the For the trialtrial of the MEWS, of the MEWS,

Removed notifying the physician at a Removed notifying the physician at a score of 4score of 4

Added, then removed graphing of the Added, then removed graphing of the scoresscores

MEWS FormMEWS Form

MEWS ScoringMEWS Scoring


Did a chart review on one unit using the Did a chart review on one unit using the MEWS formMEWS form

Looked at vital signs in 40-50 chartsLooked at vital signs in 40-50 charts3 Medical (a general medical unit)3 Medical (a general medical unit)

3 Heart3 Heart

Most patients scored Most patients scored << 2 2 1 scored a 3 1 scored a 3

Nothing to trigger a MET callNothing to trigger a MET call


Trial form with one nurse/two patientsTrial form with one nurse/two patientsDone on 3 HeartDone on 3 Heart

Nurse’s opinions about potential benefit:Nurse’s opinions about potential benefit:

Concern for time to complete the formConcern for time to complete the form

An additional form to completeAn additional form to complete

Might be useful for new gradsMight be useful for new grads

Hesitant for general staff useHesitant for general staff use

Why Continue?Why Continue?

Needed a better trialNeeded a better trialDo it longer term on more patientsDo it longer term on more patients

A better trialA better trial

Use is more representative of “real life”Use is more representative of “real life”

Need to make an impact on a Low-Volume Need to make an impact on a Low-Volume event (Code Blue)event (Code Blue)

– Need to do this long term to see if it worksNeed to do this long term to see if it works

Benefits definitely outweigh BurdensBenefits definitely outweigh BurdensNothing to lose!Nothing to lose!

Continuing the TrialContinuing the Trial

Literature showed effectiveness of Literature showed effectiveness of MEWS on surgical unitMEWS on surgical unit(5)(5)..

Decision to trial on 3 Surgical (general Decision to trial on 3 Surgical (general surgical unit).surgical unit).

Continuing the TrialContinuing the Trial

Oct 26, 2010—meeting with surgical Oct 26, 2010—meeting with surgical unit staff to discuss trialunit staff to discuss trial

Start Oct. 27Start Oct. 27thth Criteria on who should be scored was Criteria on who should be scored was established with input from staffestablished with input from staff

Any immediate post-op patient > age 75Any immediate post-op patient > age 75

Immediate post-op colon resectionImmediate post-op colon resection

Any patient transferred out of ICUAny patient transferred out of ICU

Recorded for 24 hrsRecorded for 24 hrs

How It SpreadHow It Spread

4 Ortho (general orthopedic unit)4 Ortho (general orthopedic unit)Temporarily merged with 3 SurgicalTemporarily merged with 3 Surgical

Started December 2010Started December 2010

Ortho criteria on who should be Ortho criteria on who should be scored was revised scored was revised

Any patient > 65 years of age with…Any patient > 65 years of age with…hip fractures or joint replacementship fractures or joint replacements

Any patient with PCA with a basalAny patient with PCA with a basal

Any patient with epiduralsAny patient with epidurals

Input from Evidence-Based Practice Input from Evidence-Based Practice CommitteeCommittee

Nurses on both units Nurses on both units Felt it was easy to useFelt it was easy to use

Stated it was helpful in identifying at-risk Stated it was helpful in identifying at-risk patientspatients

Recommended that MEWS be spread to Recommended that MEWS be spread to other unitsother units

Criteria for use identifiedCriteria for use identifiedSee next slide…See next slide…

Criteria for Use of MEWSCriteria for Use of MEWS

How It Spread FurtherHow It Spread Further

Form rolled out to other medical units on a Form rolled out to other medical units on a unit by unit basis during Feb, 2011unit by unit basis during Feb, 2011

Trigger to help nurses remember to use the Trigger to help nurses remember to use the MEWSMEWS

Attached to transfer out of ICU ordersAttached to transfer out of ICU orders

Attached to post-surgical vitals flow sheetsAttached to post-surgical vitals flow sheets

Signs posted on all units with criteriaSigns posted on all units with criteria

Scoring tool was made a permanent part of Scoring tool was made a permanent part of recordrecord

Benefits of the MEWSBenefits of the MEWS

Increased frequency of monitoring Increased frequency of monitoring and assessments in high-risk patientsand assessments in high-risk patientsCan trend data on form to better Can trend data on form to better identify subtle changesidentify subtle changesIncreases communication among Increases communication among healthcare providershealthcare providers

Shift-to-shift reportShift-to-shift reportReport between disciplinesReport between disciplines

Increased Critical Thinking knowledgeIncreased Critical Thinking knowledge

Benefits of the MEWSBenefits of the MEWS

Saves Lives!Saves Lives!No Code Blues on patients assessed No Code Blues on patients assessed with the MEWS so farwith the MEWS so far

There have been several MET calls There have been several MET calls based on MEWS scoresbased on MEWS scores

Case studiesCase studies

Case StudyCase Study

49 yr old patient had incarcerated 49 yr old patient had incarcerated umbilical hernia with small bowel umbilical hernia with small bowel resection.resection.

Immediate post-op MEWS score—1Immediate post-op MEWS score—1

6 hrs post-op MEWS score—46 hrs post-op MEWS score—4Urine output droppingUrine output dropping

Nurse was monitoring frequentlyNurse was monitoring frequently

7 ½ hrs post-op MEWS score—57 ½ hrs post-op MEWS score—5MET call and interventionMET call and intervention

Case StudyCase Study

79 yr old male post-op hemicolectomy79 yr old male post-op hemicolectomyInitial post-op MEWS—4Initial post-op MEWS—4

Every 2 hr vitals until MEWS 1Every 2 hr vitals until MEWS 1

20 hrs post-op MEWS—320 hrs post-op MEWS—3Every 2 hr vitals and MEWS continuedEvery 2 hr vitals and MEWS continued

24 hrs post-op MEWS—5 24 hrs post-op MEWS—5 MET call and physicians contacted for MET call and physicians contacted for treatmenttreatment

Who should it be used for?Who should it be used for?

Current criteria need to be revisedCurrent criteria need to be revisedReview of med-surg codes in 2010Review of med-surg codes in 2010

Only 17% of patients would have met criteria Only 17% of patients would have met criteria for having MEWS monitoredfor having MEWS monitored

Most MET calls/events happen >24 hrs Most MET calls/events happen >24 hrs after admission or surgery.after admission or surgery.Primary reason for MET calls in 2010Primary reason for MET calls in 2010

Respiratory distress—41%Respiratory distress—41%Change in level of responsiveness—28%Change in level of responsiveness—28%Acute change in BP/Heart Rate—20%Acute change in BP/Heart Rate—20%

BarriersBarriers

Cannot automate tool.Cannot automate tool.CareCast not an option at this pointCareCast not an option at this pointEPIC? EPIC?

Would require one line for MEWS score and Would require one line for MEWS score and one for level of responsivenessone for level of responsiveness

For surgical patients, an additional piece For surgical patients, an additional piece of paper for staffof paper for staff

Staff buy-inStaff buy-inConsistent useConsistent use

Number of MET calls/1000 Number of MET calls/1000 discharges vs. Number of Code discharges vs. Number of Code Blues/1000 dischargesBlues/1000 discharges

0

5

10

15

20

25

30

35

Oct-10 Nov-10 Dec-10 Jan-11 Feb-11

MET calls

Code Blues

Number of MET calls vs. Number of Number of MET calls vs. Number of Code Blues outside of ICU/Cath labCode Blues outside of ICU/Cath lab

0

5

10

15

20

25

30

35

Oct-10 Nov-10 Dec-10 Jan-11 Feb-11

MET Calls

Code Blues

0

5

10

15

20

25

3rd Q Oct Nov Dec Jan Feb

Surgical UnitsMedical Units

MET Calls/1000 pt days—Surgical vs. MET Calls/1000 pt days—Surgical vs. Medical UnitsMedical Units

SummarySummary

This is very preliminary dataThis is very preliminary data

Early in process of trialing this formEarly in process of trialing this form

Recommendations:Recommendations:Further education of staff and physiciansFurther education of staff and physicians

Incorporation into EPICIncorporation into EPIC

Refine criteria for which patients to use Refine criteria for which patients to use the MEWS on (not an issue if it is the MEWS on (not an issue if it is included in EPIC)included in EPIC)

Summary—Final ThoughtsSummary—Final Thoughts

Benefits outweigh BurdensBenefits outweigh Burdens

Worth further trialing for improved Worth further trialing for improved patient outcomespatient outcomes

Great promise of ease of use with Great promise of ease of use with EPICEPIC

Questions?Questions?

Thanks for Coming!Thanks for Coming!

Rita BorrettRita [email protected]

Elisia Heidt-PenrodElisia [email protected]

Thanks to Teresa Gavin, RN, MS, Thanks to Teresa Gavin, RN, MS, CCRN, Clinical Nurse Specialist, CCRN, Clinical Nurse Specialist, Critical CareCritical Care

ReferencesReferences

1.1. Institute for Healthcare Improvement (2007). Institute for Healthcare Improvement (2007). Early warning systems: Scorecards that Early warning systems: Scorecards that save lives. Retrieved from save lives. Retrieved from http://www.ihi.org

2.2. Mitchell, IA, McKay, H, Van Levan, C, Berry, Mitchell, IA, McKay, H, Van Levan, C, Berry, R, McCutcheon, C, Avard, B.,…Lamberth, P R, McCutcheon, C, Avard, B.,…Lamberth, P (2010). A prospective controlled trial of the (2010). A prospective controlled trial of the effect of a multi-faceted intervention on early effect of a multi-faceted intervention on early recognition and intervention in deteriorating recognition and intervention in deteriorating hospital patients. hospital patients. Resuscitation, 81Resuscitation, 81, 658-, 658-666. doi: 666. doi: 10.1016/j.resuscitation.2010.03.00110.1016/j.resuscitation.2010.03.001


3.3. Maupin, J & Boggs, K (2010). Hospital Maupin, J & Boggs, K (2010). Hospital develops early warning system. develops early warning system. Healthcare Healthcare Risk Management, 32, Risk Management, 32, 92-94.92-94.

4.4. Moon, A, Cosgrove, JF, Lea, D, Fairs, A, & Moon, A, Cosgrove, JF, Lea, D, Fairs, A, & Cressey, DM (2011). An eight year audit Cressey, DM (2011). An eight year audit before and after the introduction of modified before and after the introduction of modified early warning score (MEWS) charts, of early warning score (MEWS) charts, of patients admitted to a tertiary referral patients admitted to a tertiary referral intensive care unit after CPR. intensive care unit after CPR. Resuscitation, Resuscitation, 8282, 150-154. doi: , 150-154. doi: 10.1016/j.resuscitation.2010.09.48010.1016/j.resuscitation.2010.09.480


5.5. Maccarone, M, Guerri, I, Franchi, M, Fricelli, C, Maccarone, M, Guerri, I, Franchi, M, Fricelli, C, Perretta, L, Zagli, G, Spina, R, Linden, M, Perretta, L, Zagli, G, Spina, R, Linden, M, Bonizzoli, M, Peris, A (2010). Impact of a Bonizzoli, M, Peris, A (2010). Impact of a systematic MEWS introduction on preoperative systematic MEWS introduction on preoperative and postoperative evaluation in and postoperative evaluation in urgent/emergency surgery. urgent/emergency surgery. Critical Care, 14 Critical Care, 14 (Suppl 1): (Suppl 1): P255P255

6.6. Subbe, CP, Kruger, M, Rutherford, P, & Subbe, CP, Kruger, M, Rutherford, P, & Gemmel, L (2001). Validation of a modified Gemmel, L (2001). Validation of a modified Early Warning Score in medical admissions. Early Warning Score in medical admissions. Q J Q J Med, 94Med, 94, 521-526., 521-526.

Use the MEWS: Help Keep Our Patients Safe Rita Borrett, RN, BSN, CMSRN Nurse Manager, 3 Surgical...

Documents

Transcript of Use the MEWS: Help Keep Our Patients Safe Rita Borrett, RN, BSN, CMSRN Nurse Manager, 3 Surgical...