Early warning system cuts code blues by 50%
Calls for RRT increase, too
Though the utility of the rapid response team on decreasing mortality has been questioned in recent literature, no one disputes the importance of early recognition of patient deterioration or subsequent early intervention. That, unequivocally, is a big part of not only decreasing codes but decreasing mortality and making hospitals more productive in what they do — care for patients.
When Janice M. Maupin, RN, MSN, CPHQ director, quality services at Mercy Hospital Anderson in Cincinnati, OH, began looking at systems for recognizing patient deterioration, she found very little research or work being done in the United States outside of pediatric hospitals. However, in the UK she found quite a lot of work and literature on the topic. After implementing a scoring system she found in that literature,1 the hospital not only dropped its code blues outside of the ICU by 50% and increased its rapid response team calls 110%, but it garnered some attention from The Joint Commission.
The hospital was among the recipients of The Joint Commission's 2009 John M. Eisenberg Patient Safety and Quality Award winners, specifically noted for innovation in patient safety and quality at the local level.
Mercy Hospital Anderson rapid response path
On its journey to building an early detection and rapid response for deteriorating patients, Mercy Hospital Anderson implemented a rapid response team in 2005 as part of the Institute for Healthcare Improvement's 100,000 Lives Campaign. But Maupin was disappointed with the results she was seeing post-implementation.
"No. 1, we really didn't see a whole lot of rapid response teams called. And No. 2, we still had pretty much the same number of code blues outside the ICU that we had before. It decreased a little bit, but not really significantly," she says.
So the team started looking at the code blues and "noticed that you could see that prior to the arrest, the nurse had quite a bit of documentation about the patient being restless and calling frequently for multiple things, couldn't sleep, and wanted a sleeping pill, etc.," Maupin says. "You could obviously see that the patient was very restless in the hours prior to the code. But when you looked at individual vital signs, they really hadn't significantly changed."
Nurses had been using one parameter, one vital sign, as a signal to call for an RRT — for instance, if the patient's heart rate was above 120 or blood pressure was below 80, an RRT was called. "It took awhile before you really started seeing significant changes in vital signs like that. But we did start seeing all this restlessness documented. So we knew that there were warning signs prior to a code. We just didn't really know how to put our finger on them," Maupin says.
It had been almost two years since the hospital had started it rapid response team initiative. She heard from a colleague about work being done in the UK on a modified early warning scoring (MEWS) system. "So we decided to take a look at this MEWS score. What it is is a way to apply an objective number to the patient's vital signs and use a multiparameter approach to tally up all the vital signs and give it one score," she says.
The scoring system calculates physiological parameters including heart rate, blood pressure, respiratory rate, temperature, and central nervous system status. The patient's score then informs the nurses' action. Maupin says Chris Subbe, MD, was able to show that a score of five or six correlated with a significantly higher risk of mortality. If a nurse at Mercy Hospital Anderson sees a score of zero to two, he or she would continue monitoring as usual.
"But then as a patient progressively gets a higher score, we progressively increase our nursing surveillance by increasing vital sign frequency or letting our clinical administrator, who is ACLS [advanced cardiac life support] certified, know to assess the patient," Maupin says.
The scoring system was first piloted on one floor. The unit nurses saw the benefits immediately, she says. And while the original plan had been to test it for three months before spreading it to other units, "after two months, we were having such good success and didn't have any codes on the pilot unit for those two months. And rapid response team calls increased by over 200% on that one unit. We decided to shorten the pilot and go housewide because nurses were already starting to spread it out on their own. They would come up to that floor and learn how to use it and then they would start taking it back to their own unit," she says.
Maupin thinks the ease of use contributed to the system's successful implementation. She worked with the hospital's IT department to make it as automatic as possible. There's still a few manual clicks, she says, but most is automated. "That really did help," she says. "I wouldn't have been able to implement one more form that the nurse had to complete. They just wouldn't have done it."
For the first month or so, she characterizes the implementation as labor intensive for her quality department, as "we had to really be out there all the time working with nurses and coaching them and getting them to try it. We had to convince them it wasn't going to add a lot of time to their day." But overall implementation, she says, was really pretty easy.
They've just begun to use the system in the emergency department. "We were starting to notice that occasionally we'd have patients who were transferred up from the ED to the med/surg floors and, when the nurse went in to assess the patient, found that emergency attention or even transfer to ICU was needed immediately. So we implemented a process for the emergency room nurses to calculate a MEWS score 30 minutes prior to the transfer out of the ER. And then if the patient was a 4 or higher, the transfer stopped," and the patient would be reassessed and possibly assigned to a higher level of care, she says.
Why were the results post-implementation of the MEWS scoring system so positive?
Before, she says, when nurses were looking at only one vital sign to signal deterioration, the measure chosen wasn't sensitive enough. "And that vital sign would have needed to be way out of range and sometimes that might have been too late to call." And without a lot "of continuity of care" in hospitals today and demanding work hours, nurses might not notice that something is just not right with a single patient.
Nurses now calculate a MEWS score for each patient every 12 hours, the first set taken on admission. Every 12 hours a report is printed and reviewed by the clinical administrator, who also staffs the rapid response team alongside a respiratory therapist. She follows up on every patient whose score is above three.
Maupin counts the reasons for the success. No. 1, it was not added as an additional thing nurses needed to do. Make it as simple as possible for the staff and work it into things they already do, she advises quality managers.
She also recommends having a process in which your house supervisor, clinical administrator, charge nurse, etc., is responsible for making sure the scores are being calculated and that at-risk patients (those with a score of three or higher) are followed up on appropriately. And give feedback to staff, especially compliant staff. "In the beginning, we kept track of every single time that they used the MEWS score and called a rapid response team and had a good outcome from it and prevented a code. We would tell those stories. Just celebrate every single success," she advises. She would also publicly display the names of nurses using the system.
She says there's still room for improvement on compliance. Sometimes, she says, the nurses get busy and feel they've gotten to the point where they can intuitively tell what the score would be and they don't need to calculate an actual score. But the goal is to get everyone to use it every time.
It's also empowered nurses to call for help from the RRT. "I think that's been a major benefit in this. Especially with newer nurses who may not be real confident yet in their assessment skills when calling the physician. Especially with that patient where they do have that feeling that something's just not right here but you don't really know what to say to the physician," she says.
"Any individual single vital sign may not be that far out of range. But when you tally them all together, you can start seeing an issue. And I think that objective number has really helped some of the nurses."
Looking retrospectively at codes called in 2007, Maupin realizes so many could have been avoided with the use of the MEWS system. "We applied the MEWS score retrospectively to the vital signs documented within 24 hours prior to the code."
They found in 60% of the cases that if the MEWS system had been used they likely could have prevented the codes. They found the average warning time was 6.6 hours. "So 6.6 hours prior to the code, if we had been using MEWS, we could have identified the patient and maybe done something to intervene to prevent the code blue."
Reference
- Subbe, C.P. et al. Validation of a modified early warning system in medical admissions. Q J Med 2001, 94:521-526.
[For more information, contact:
Janice M. Maupin, RN, MSN, CPHQ director, quality services, Mercy Hospital Anderson, Cincinnati, OH. E-mail: [email protected].]
Though the utility of the rapid response team on decreasing mortality has been questioned in recent literature, no one disputes the importance of early recognition of patient deterioration or subsequent early intervention.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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