Use the MEWS: Help Keep Our Patients Safe Rita Borrett, RN, BSN, CMSRN Nurse Manager, 3 Surgical Elisia Heidt-Penrod, RN, BSN Nurse Manager, 4 Ortho

Introduction Dr. Jeff Crandall Medical Director of Clinical Initiatives Iowa Health System

Code Buster A3

Why We Started Number of Code Blues Outside of ICU Multidisciplinary Critical Care Committee Medical Emergency Team (MET) Rapid Response Team Code Blues outside of the ICU continue Lack of vital signs within the few hours leading up to cardiopulmonary arrest

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

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

Calls to the MET Calls are generally triggered: one very abnormal vital sign worry about the patient Average of 22 calls/month in 2009 Average of 24 calls/month in 2010 Average of 14 calls/month in 2011

Allen’s Criteria for Calling MET

Allen’s MET Criteria MET calls triggered by isolated criteria that are extremely abnormal May not identify some of the more subtle signs indicating deterioration May not identify deterioration at an early stage

Better identification pre-code… Would scoring multiple criteria help to identify patients with subtle warning signs earlier? Modified Early Warning Scoring System (MEWS) Examines multiple criteria Aggregate scoring of multiple criteria

What the Literature Says Modified Early Warning Scores (MEWS)(1,2) Respirations Heart Rate Systolic B/P Level of Consciousness Temperature Additional assessments as score increases Urine output O2 Saturation

What the Literature Says Value of rapid response teams Help to decrease incidence of cardiac arrests by responding rapidly (1) Earlier recognition results in earlier assistance Problem: when to contact the rapid response team? Usually contacted with significant change in vital signs or “something isn’t quite right” with the patient(1) But, could improve response if contacted BEFORE a significant change in vital signs occurred

What the Literature Says Early Warning Scoring System (EWS)(4,6) Designed to identify subtle vital sign changes earlier in surgical patients Scores multiple criteria Updated to Modified Early Warning System (MEWS)(4) Further potential for identifying other (e.g., medical) patients who were at risk Added O2 sat and urine output Quantifies criteria into a single score that triggers intervention

MEWS Modified Early Warning Scoring System helps to identify signs of deterioration earlier (3) Earlier recognition leads to fewer codes (3) Not a great deal of research support, But benefits dramatically outweigh burdens…

What the Literature Says MEWS helps to identify patients at risk for deterioration sooner and save lives! Decreased cardiac arrests/code blue calls (1,3,4) Increased MET calls (1,2,3) Decreased unexpected deaths (2,4,5) Decreased unplanned admission to ICU (2,5)

What the Literature Says MEWS empowers nurses(3) to know when to: continue monitoring and routine care increase monitoring of VS and when to inform others of subtle changes notify the physician contact the MET team

How We Started A3 done by Dr. Crandall in June 2010 which proposed use of MEWS Development of MEWS form for Allen Hospital For the trial of the MEWS, Removed notifying the physician at a score of 4 Added, then removed graphing of the scores

MEWS Form

MEWS Scoring

MEWS Scoring

MEWS Scoring

How We Started Did a chart review on one unit using the MEWS form Looked at vital signs in 40-50 charts 3 Medical (a general medical unit) 3 Heart Most patients scored < 2 1 scored a 3 Nothing to trigger a MET call

How We Started Trial form with one nurse/two patients Done on 3 Heart Nurse’s opinions about potential benefit: Concern for time to complete the form An additional form to complete Might be useful for new grads Hesitant for general staff use

Why Continue? Needed a better trial Do it longer term on more patients Use is more representative of “real life” Need to make an impact on a Low-Volume event (Code Blue) Need to do this long term to see if it works Benefits definitely outweigh Burdens Nothing to lose!

Continuing the Trial Literature showed effectiveness of MEWS on surgical unit(5). Decision to trial on 3 Surgical (general surgical unit).

Continuing the Trial Oct 26, 2010—meeting with surgical unit staff to discuss trial Start Oct. 27th Criteria on who should be scored was established with input from staff Any immediate post-op patient > age 75 Immediate post-op colon resection Any patient transferred out of ICU Recorded for 24 hrs

How It Spread 4 Ortho (general orthopedic unit) Temporarily merged with 3 Surgical Started December 2010 Ortho criteria on who should be scored was revised Any patient > 65 years of age with… hip fractures or joint replacements Any patient with PCA with a basal Any patient with epidurals

Input from Evidence-Based Practice Committee Nurses on both units Felt it was easy to use Stated it was helpful in identifying at-risk patients Recommended that MEWS be spread to other units Criteria for use identified See next slide…

Criteria for Use of MEWS

How It Spread Further Form rolled out to other medical units on a unit by unit basis during Feb, 2011 Trigger to help nurses remember to use the MEWS Attached to transfer out of ICU orders Attached to post-surgical vitals flow sheets Signs posted on all units with criteria Scoring tool was made a permanent part of record

Benefits of the MEWS Increased frequency of monitoring and assessments in high-risk patients Can trend data on form to better identify subtle changes Increases communication among healthcare providers Shift-to-shift report Report between disciplines Increased Critical Thinking knowledge

Benefits of the MEWS Saves Lives! No Code Blues on patients assessed with the MEWS so far There have been several MET calls based on MEWS scores Case studies

Case Study 49 yr old patient had incarcerated umbilical hernia with small bowel resection. Immediate post-op MEWS score—1 6 hrs post-op MEWS score—4 Urine output dropping Nurse was monitoring frequently 7 ½ hrs post-op MEWS score—5 MET call and intervention

Case Study 79 yr old male post-op hemicolectomy Initial post-op MEWS—4 Every 2 hr vitals until MEWS 1 20 hrs post-op MEWS—3 Every 2 hr vitals and MEWS continued 24 hrs post-op MEWS—5 MET call and physicians contacted for treatment

Who should it be used for? Current criteria need to be revised Review of med-surg codes in 2010 Only 17% of patients would have met criteria for having MEWS monitored Most MET calls/events happen >24 hrs after admission or surgery. Primary reason for MET calls in 2010 Respiratory distress—41% Change in level of responsiveness—28% Acute change in BP/Heart Rate—20%

Barriers Cannot automate tool. Staff buy-in Consistent use CareCast not an option at this point EPIC? Would require one line for MEWS score and one for level of responsiveness For surgical patients, an additional piece of paper for staff Staff buy-in Consistent use

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

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

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

Summary This is very preliminary data Early in process of trialing this form Recommendations: Further education of staff and physicians Incorporation into EPIC Refine criteria for which patients to use the MEWS on (not an issue if it is included in EPIC)

Summary—Final Thoughts Benefits outweigh Burdens Worth further trialing for improved patient outcomes Great promise of ease of use with EPIC

Questions?

Thanks for Coming! Rita Borrett Elisia Heidt-Penrod BorretRA@ihs.org Elisia Heidt-Penrod HeidtEL@ihs.org Thanks to Teresa Gavin, RN, MS, CCRN, Clinical Nurse Specialist, Critical Care

References Institute for Healthcare Improvement (2007). Early warning systems: Scorecards that save lives. Retrieved from http://www.ihi.org Mitchell, IA, McKay, H, Van Levan, C, Berry, R, McCutcheon, C, Avard, B.,…Lamberth, P (2010). A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation, 81, 658-666. doi: 10.1016/j.resuscitation.2010.03.001

References Maupin, J & Boggs, K (2010). Hospital develops early warning system. Healthcare Risk Management, 32, 92-94. Moon, A, Cosgrove, JF, Lea, D, Fairs, A, & Cressey, DM (2011). An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation, 82, 150-154. doi: 10.1016/j.resuscitation.2010.09.480

References Maccarone, M, Guerri, I, Franchi, M, Fricelli, C, Perretta, L, Zagli, G, Spina, R, Linden, M, Bonizzoli, M, Peris, A (2010). Impact of a systematic MEWS introduction on preoperative and postoperative evaluation in urgent/emergency surgery. Critical Care, 14 (Suppl 1): P255 Subbe, CP, Kruger, M, Rutherford, P, & Gemmel, L (2001). Validation of a modified Early Warning Score in medical admissions. Q J Med, 94, 521-526.