1. Use of Early Warning Scores To Detect Patient Deterioration: PEWS, MEWS & Sepsis
Patricia Conlon, APRN, CNS, CNP, M.S.
Courtney Stellpflug, APRN, CNS, M.S.
MN NACNS 2017 Annual Meeting & Conference
October 27, 2017
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2. Pediatric Early Warning Signs (PEWS) & Sepsis Screening

3. Background to PEWS
The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety
The first set of NPSGs was effective January 1, 2003
The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs
Rapid Response Teams were developed to address an acute inpatient clinical decompensation
Successful development of pediatric and adult code teams, deaths outside of the ICU were not eliminated.
PEWS 2005 Monaghan, Children’s Hospital in Brighton, England
Monaghan A.
Detecting and managing deterioration in children.
PAEDIATR Nurs 2005, 17(1):32-35

4. Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration
Evaluation of PEWS as an indicator to RRT
Hypothesis: 80% RRTs are preceded by a critical PEWS
RRTs reviewed 10/ /2008 (n=170)
Critical PEWS median 11 hours prior in 85%, 80 min for 97.1%
Earliest preceding time was 30 min
PEWS forewarning time >11 hours
Children’s Hospitals and Clinics of Minnesota, Minneapolis and Rady Children’s Hospital in San Diego

5. PEWS implementation Data reviewed National benchmarking
ERT & RRT data
Mortality review
National benchmarking
Literature review
PEWS Quality Improvement Pilot
2 week pilot was conducted from April 22- May 6, 2013
9 RNs educated on how to use the tool
Data was collected on tool usability and ability to identify patients at risk of deterioration
24 patients assessed using the PEWS
Additional 6 patient records were reviewed post Rapid Response Team (RRT) activation or post deterioration
Research literature review: it has become evident that through the research, PEWS has been proven to increase detection of deterioration and is quickly becoming a standard of care in many pediatric inpatient hospitals.
Because we knew that PEWS was available in EPIC, it was important for staff to get education begin feel comfortable with this assessment tool before

6. PEWS Quality Improvement Pilot Outcomes
Of the 24 patients, none demonstrated any deterioration or compromise
Of the six patient records that were reviewed, the PEWS scoring system would have accurately captured the deterioration of these children.
Nurses reported the tool is valuable and easy to follow
Of the 24 patients in whom data was collected did not demonstrate any deterioration or compromise
Of the six patient records that were reviewed, the PEWS scoring system would have accurately captured the deterioration of these children. However, the nurses caring for these six patients were aware of the patient deterioration and were intervening appropriately in the absence of the tool being used
PEWS scoring system would have accurately captured the deterioration of these children

7. Pediatric Early Warning Signs (PEWS) was implemented Sept. 2016

8. PEWS algorithm

9. # Rapid Response Team calls largely unaffected by PEWS implementation

10. Number PEWS with a score of 4 or above is low
2017
June: 3%
July: 4.5%
August: <1%
September: <1%
The higher the PEWS score, the higher the risk
Is a conversation starter for the RN to report concerns to provider
Can watch trend over time
More objective than “gut feeling” for providers

11. Sepsis screening

12. Improving Pediatric Sepsis Outcomes (IPSO)
National collaborative through the Children’s Hospital Association with 47 hospitals as of July 2017
Aim: Reduce mortality and hospital-onset severe sepsis by 75% in the United States pediatric acute care setting by 12/2020
Key areas of focus:
Prevention
Recognition
Diagnostic Evaluation
Resuscitation/Stabilization
De-escalation
Patient and Family Engagement
Optimize performance

14. Background
Severe sepsis has a mortality rate estimated between 8.2%-21.2% in the United States
Prevalence estimated at 4.4% of hospitalizations in 2012
Median hospital length of stay: days
Median hospital costs per patient: Between $52,000-$65,600
(Balamuth et al., 2014)

15. Pediatric Challenges Symptoms can vary Age-specific guidelines
Children can compensate well
Hypotension presents later
Immature immune system relative to adults
(Randolph & McCulloh, 2014)

16. Screening tool was adapted from the Pediatric Septic Shock Collaborative (PSSC) Sepsis Identification Tool and used with permission from CHA.

17. Sepsis team documentation done within 30 minutes of positive sepsis screen at bedside

18. Sepsis Pilot Results The tool was easy to use.
Majority of people estimated that it took less than 60 seconds to complete
Accurate assessment of potential sepsis
PDSA Cycle #1 (nurses using the tool on anyone; didn't collect patient data) 
10 positive screenings 
70 negative screenings
Subsequent PDSA cycles
13 positive screenings
5 of which the service was not notified or they were already aware of the situation and a huddle was not completed
8 had a huddle completed
177 negative screenings 

19. Current state PEWS can be normal and sepsis screen positive
PEWS can be 4 or more and sepsis screen is negative
PEWS being screened with all routine vital signs
Frequency varies according to reason for admission
Sepsis is screened
Morning and evening e.g. 8am and 8pm.
Per nursing assessment when clinically indicated

20. Modified Early Warning Score (MEWS)
Courtney Stellpflug, APRN, CNS

21. Why MEWS?
Patient Survival Recognizing patient deterioration EARLY
We most commonly recognize sepsis in severe and shock stages – mortality rate is then 50%
Clinical deterioration can be seen through subtle changes in a number of parameters as well as large changes within a single variable.
Sepsis turns deadly when it is not quickly recognized and treated
Centers for Disease Control and Prevention, 2016

22. General Medical Thoracic Unit Background
Rapid Response Team (RRT) call data
Transfers to a higher level of care
Mortality trends
Time from admit to the care unit
Communication (pager/surveys)
Top 2 Reasons for RRT Calls:
1. Progressive Acute Respiratory Failure
Oxygen device escalation/support
2. Sepsis
Medications, Fluids, Monitoring

23. General Care Medical Thoracic Unit Pilot
Implementation of MEWS
Development of a Graded Response System
Structured Evening & Night Rounding
Nursing Protocol: Sepsis Screening with Lactate

24. Intervention: MEWS
Bedside RN calculates MEWS with each vital sign check
All patients on Do 6B
Notifies provider when appropriate (3 or higher)
Trending MEWS throughout the day/stay

25. Intervention: MEWS
Limitation: Early identification of respiratory failure
Addition of oxygen titration questions:

26. Interventions: Graded Response
When to notify providers
Timeliness to bedside – Pulmonary Service
2 pathways for intervention intensity appropriateness – Pulmonary Service
Patients with a medium or high MEWS score should have:
Appropriate interventions initiated
Sepsis
Progressive acute respiratory failure
Reassess intervention to see if situation reverses or progresses

27. Interventions: Evening Rounds
Respiratory Therapist and charge RN
Midnight & 0400
Pulmonary Patients, New Admits
Patients requiring oxygen (right device, right amount)
Pulmonary resident and charge RN
2100, chest room
MEWS trends throughout the day
Subjective criteria
Stable, Watcher, Unstable
Plan for the night

28. Interventions: Evening Rounds

29. Interventions: Sepsis Screening
Sepsis Screening Protocol
Nurse initiated protocol for lactate draw
MEWS or qSOFA criteria
MEWS 4 or greater
Final: MEWS of 4 and qSOFA criteria

30. Metrics: Alert Frequency & Bedside Evaluations
Patients with a MEWS of 3 or higher: Trended down with pilot
Average MEWS for RRT and ICU transfers: 4.2
Keep ‘3’ as a positive score for general care
Subset of patients in an area may trend moderate scores: CF Patients
Intervention intensity
Less aggressive when bedside evaluation not performed by provider
The September group phenomenon
Reasons for provider notification with MEWS less than 3
Hypertension in patients who normally have a low SBP

31. Metrics: Vital Signs & RRT Calls
Nurses trending abnormal vital signs:
Recheck 30 minutes if abnormal value
Full set recheck: 50% increase
RRT calls:
Collaborative RRT Calls: 54% increase
Volumes: No significant change
Late calls & multiple calls on a single patient: decreased
Interventions intensity improves prior to RRT

32. Metrics: Mortality Rates

33. Metrics: Communication
Pager volumes increased (less at night)
Provider survey reports feeling pages were less
Nursing & provider surveys reported overall improvement
Nursing reports paging providers earlier using MEWS criteria
Increase in provider awareness of patient deterioration prior to RRT calls

34. Metrics: Communication
Nursing Surveys: Perception of Patient Outcomes
Perceived improvement in patient outcomes with pilot interventions in place
Provider Surveys: Perception of Effort & Burden
Pre surveys anticipating process to be burdensome, post surveys reveal ‘not burdensome’

35. Staff Comments Nursing: Residents:
Newer staff report they appreciate having objective criteria to call to provider
Some experienced staff state they know the patient is deteriorating as the MEWS increases
Residents:
Less cases of RRT calls without service aware of patient deterioration
Improved nursing/physician relationship & communication with Chest service (redcap)

36. Keys for Success: Collaboration
Plan for Alert Response
Expected outcomes or actions for MEWS alerts
Value of provider to bedside to evaluate
Appropriate interventions determined for the patient population
Area (unit/site) specific data (RRT/ ICU transfers/ mortalities) to focus on recommendations for alert responses
Intervention intensity
Timeliness of interventions & patient evaluation

37. Keys for Success: Collaboration
Communication
Between nursing staff and providers
Discussing changes in patient condition & score
Follow up to interventions
Nursing and physician champions