From Reactive to Proactive TO DETERMINE THE POTENTIAL EFFECTIVENESS OF THE EARLY WARNING SCORE (EWS) SYSTEM IN THE IDENTIFICATION OF DETERIORATING PATIENTS WITH SUBTLE WARNING SIGNS Marie Cabanting, M.D. Rikka Banayat, M.D. Sizan Patel, M.D. Sidney Ceniza, M.D. Chandni Merchant, M.D. Doantrang Du, M.D. Patricia Marcell, R.N. Joseph Cagliostro, R.N. Rose Mary O Gara Yasmin Ahmed Richard Eng
Background Clear and detectable signs of deterioration in many patients before a serious life-threatening events or death. Efforts to develop and implement systems to intervene at the earliest. The nationwide implementation of the Rapid Response Team (RRTs).
Background Despite the deployment of Rapid Response Teams (RRT),according to Odell (2010), timely detection and appropriate management of deteriorating ward patients still remain a problem. A study analyzing patient safety incidents reported that a number of patients had died because their deterioration had not been recognized or acted on The Early Warning Score System is an evidence-based physiological scoring system that has been successfully implemented in the UK.
Background Assignment of risk scores for clinical deterioration based on vital signs and clinical observation. A descriptive step by step guide or algorithm of actions based on the patient s assessment score. The Royal College of Physicians in the UK has recommended the use Early Warning Score (NEWS) to standardize clinical assessment across their health system. By incorporating the use of the NEWS, non-icu patients clinical deterioration will be recognized earlier resulting in a proactive referral and thus, intervention at the earliest point as possible. Our study aimed to improve patient care and outcomes.
Objectives General Objective: To retrospectively calculate the Early Warning Score (EWS) of patients in whom Rapid Response Team (RRT) was called from January 1, 2013 to December 31, 2013 and correlate these to the outcome of the RRT.
Objectives Specific Objectives: A. To determine the EWS of patients at the time of the RRT activation B. For patients who had EWS of moderate and high at the time of RRT activation, we wanted to determine the number of hours from the time of RRT to the time when EWS is low (green) C. To correlate the EWS with the outcome of the RRT; outcomes include Code Blue, unplanned transfer to the ICU, and death.
Methods 581 patients who had an RRT. Duration: Jan 2013 to Dec 2013. 83 excluded out of 581 Exclusion Criteria Patients with OBRRT Code STEMI Code Stroke RRTs with inappropriate documentation
Methods /NEWS score IRB approval 498 Charts reviewed from RRT database 3 2 1 0 1 2 3 Heart rate Less than 40 / min 41 to 50 /min 51 to 90/ min 91 to 110 /min 110to 130 /min Greater than or = 131 Temperature less than or equal 95 F 95.1-96.8 F 96.9 to 100.4 F 100.5 to 102.2 F Greater than 102.3 F Systolic BP Less than or = 90 mm Hg 91-100 mm Hg 101-110 mm Hg 111-219 mm Hg Greater than or = 220 mm Hg Oxygen saturation Less than 91% 92-93% 94-95% Greater than 96% Suplemental oxygen use yes No or NA Respiratory rate Less than 8 per minute 9 to 11 per minute 12 to 20 per minute 21 t 24 per min 25 per min or greater Level of consciousnes A or NA V, P or U = D
Interpretation of NEWS score NEWS score was classified in to: Low risk 0-4 (indicated in green), Moderate risk 5-6 (indicated in yellow) High risk 7 or more (indicated in red)
Interpretation of NEWS score Most recent set of vital signs before or at the time of the RRT, NEWS :To Prior to the occurrence of the RRT, T1 Time at which NEWS score : low risk for that patient, T2 Additional data : reason for the RRT, basic patient information (age, gender, date of admission and discharge) and the disposition were reviewed. The disposition : - patient maintained on the same medical floor, - or transferred to a higher level of care like telemetry or ICU, - or change of goals of care to palliative care/hospice. - RRT to Code Blue or cardiorespiratory arrest, and/or death of a patient.
GOAL: to observe the time interval between the initial signs of deterioration to the activation of a Rapid Response; thereby, gauging the impact of implementation of NEWS score in our hospital on patient outcomes.
Results: Sex and Risk Categories 498 cases studied Males 38% Females 62% Score: 0-4 = Low Risk 48% Score: 5-6 = Moderate Risk 21% Score: 7 = High Risk 31% Score: 7 = High Risk 33% Score: 0-4 = Low Risk 46% Figure 2. Distribution of Female RRT cases into different risk categories Score: 5-6 = Moderate Risk 21% Figure 1. Risk categories based on NEWS at the time of RRT Females 62% Males 38% Score: 0-4 = Low Risk 44% Score: 5-6 = Moderate Risk 20% Score: 7 = High Risk 36% Figure 3. Distribution of Male RRT cases into different risk categories
Disposition Transfer to ICU/CCU 6% Transferred to Non-ICU Higher Level of Care 12% Transfer to Hospice 1% Death 0% Transferred to Non- ICU Higher Level of Care 7% Death 0% Transferred to Non-ICU Higher Level of Care 17% Death 3% Maintained 81% Transfer to ICU/CCU 25% Maintained 68% Transfer to ICU/CCU 29% Maintained 49% Transfer to Hospice 2% Low risk Moderate risk High risk
Results: Age and Risk Categories Score: 5-6 = Moderate Risk 16% Age 65 58% Age 64 42% Score: 0-4 = Low Risk 55% Score: 7 = High Risk 29% Figure 4. Distribution of RRT cases Age 64 years old into different risk categories Age 64 42% Age 65 58% Score: 0-4 = Low Risk 40% Score: 5-6 = Moderate Risk 24% Score: 7 = High Risk 36% Figure 5. Distribution of RRT cases Ages 65 years old into different risk categories
Number of RRTs over time This graph illustrates the number of RRTs on the y-axis plotted against total time interval in hours between noticing initial signs of deterioration based on NEWS and actual time of RRT. No. of Patients Fifty percent of patients who had RRTs showed initial signs of deterioration 4 hours prior to the actual RRT. Hours since RRT
Limitations Focused on adult patients only. Did not include pediatric patients and pregnant patients. Only 3 sets of Vital signs studies: To,T1 and T2. Need to look back at admission vital signs as well.
Recommendations To include other details like admitting diagnoses and comorbidities. Locations on the RRTs : floors Final discharge disposition. Include more patients to increase power of the study. Implementing the NEWS score as a pilot study.
References Akre, M., Finkelstein, M., Erickson, M., Liu, M., Vanderbilt, L., & Billman, G. (2010). Sensitivity of the pediatric early warning score to identify patient deterioration. Pediatrics, 125(4), e763-e769. Alam, N., Hobbelink, E. L., van Tienhoven, A. J., van de Ven, P. M., Jansma, E. P., & Nanayakkara, P. W. B. (2014). The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review.resuscitation, 85(5), 587-594. Kansagara, D., Smith, M. B., Chiovaro, J. C., O Neil, M., Quinones, M. A., Freeman, M.,... & Slatore, C. G. (2014). Early Warning System Scores: A Systematic Review. McGaughey, J., Alderdice, F., Fowler, R., Kapila, A., Mayhew, A., & Moutray, M. (2007). Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev, 3.
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