14 taylor panek
TRANSCRIPT
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Cardiac Surgery Early
Warning Scoring System
Washington Hospital
Center
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Cardiac Surgery Bounce Back > 48
hours Data
Identify Trends, N=13, this was for the first twoquarters of FY 2011
62% returned to SICU for Respiratory RelatedCauses
> 10% returned to the SICU for Arrythmia, Altered
Mental Status, and Hemodynamic Compromise
78% of the patients Bounced Back to the SICU onnight shift
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62% of the Bounce Backs Occurred after they hadbeen on 4 NW for at least 10 days
46% where 60-69 yrs/age, and 22% where 70-89yrs/age
45% gradual decline signs of deterioration at 12
hours
Mortality rate - 30%
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Goals:
Minimize the number of Failure to Rescue patients
Improve Patient Safety by early recognition and
intervention
Standardize Nursing Response to Changes inpatients status
Enhance Communication with all providers througheffective use of SBAR
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Modified Early Warning Score
Tool developed in England to assist ER staff inearly identification of patients who requireadmission to the hospitals
Comprised of 4 physiological parameters and 1Observational parameter
Scores are tallied from the parameters
Score of > 2 was linked with increased likelihood ofadmission
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Modified Early Warning Score
SCORE 3 2 1 0 1 2 3
SBP < 70 71-80 81-100
101-
199 130
RR < 9 9-14 15-20 21-29 > 30
Temp. < 3535-38.4
> 38.5
AVPU Alertrespond to
VoiceReacts to
PainUnres-ponsive
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Validation of the Modified Early Warning Score in
Medical Admissions: QJ Med 2001; 94: 521-526
Prospective study, data collected on 709 ptsadmitted to a Medical Admissions unit
Focus of the study to assess the ability of theMEWS to identify medical patients at risk forcatastrophic deterioration.
Patients with Scores of > 4 in this study were atincreased risk for catastrophic deterioration andScores > 5 where associated with increased risk ofdeath.
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Value of Modified Early Warning Score in Surgical In-
Patients: Annals of the Royal College of Surgery
England, 2006; 88:571-575
Prospective Observational Study - 334 pts
Goal - Increase earlier intervention
MEWS =>4 triggered a call out to the surgical team
Results: 57 pts/17% triggered MEWS =>4,16 pts/5% needed admission to the ICU and theremaining where managed on the ward
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MEWS => 4 had a Sensitivity of 75% for admissionto the ICU and was 83% specific.
They also looked at workload on the Wards usingthis tool - average census on the Ward was 18 and
the maximum amount of pts with a MEWS of = > 4was 5 with the average being 1.
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Use of the MEWS Decreased Code Blue Events: The
Joint Commision Journal on Quality and Pt.
Safety,Dec. 2009, Vol. 35 Number 12
200 Bed Community Hospital in Southwest Ohio
Goal: Decease Code Blues, Increase the call forevaluation by the RRT - Rapid Response Teamsusing a MEWS of 5 as the trigger for the call.
Provide Nursing with a tool to assist with evaluation
subtle signs that predict the likelihood ofdeterioration.
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Developed an Action algorithm: MEWS=>3Increase in frequency of Vital signs with notification
of the charge nurse, Mews =>4 also includedevaluation by the clinical administrator, and MEWS=> 5 Rapid Response call.
Outcomes: Decreased Code Blues by 50% with adecrease in overall mortality over 12 months
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Early Warning Systems: Scorecards that Save Lives;
Institute for Healthcare Improvement, 2011
Clear set of criteria
Uses multiple Parameters
Logical System - Nursess already do vitals and a
mental status exam routinely
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J ourney to CSEWS
First step: Development of an Early WarningScoring system that would reflect the needs of theCV surgical patients
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Cardiac Surgery Early Warning Score
Score 3 2 1 0 1 2 3
SBP 160
HR 130
RR 30
Resp.
Support
>6L/NC
> 50%FIO2
5-6L/NC
40-50%FIO2
1-4
L/nC RA
LOC Alert
Respond toVoice -newConfusionR
estless
Respondto Pain
Unres-ponsive
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Concurrent Review with CSEWS, Cardiac Early
Warning Scoring
May-J une 2011
80 Charts over 3 non-consecutive Days
Day 1 - 30 pts - 1 pt. with a score of =>3 : tachycardia withhypotension - no bounce back to SICU
Day 2 - 30 pts - 2 pts with a score of =>3*Bradycardia and hypertension - D/C home*Respiratory Distress, Code 1 called due to changes in LOC - nobounce back
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Day 3 - 20 pts, 3 pts scored => 31st pt.: respiratory distress, hypotensiontachycardia - no bounce back2nd pt.: hypotension, bradycardia, and lethargy - nobounce back3rd pt.: hypertension, tachycardia, oxygen supportat 2L/NC - no bounce back
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8 week Pilot: CSEWS
CSEWS calculated every 4 hours
* Score =>3 increased frequency of vitals with
notification of the covering surgical team, resourcenurse and nursing supervisor*Score =>4 increased vitals and assessment of thepatient by the covering surgical team if no
improvement in 4 hours to consider transfer to theSICU*Score =>5 Rapid Response and immediate bedsideevaluation of the patient by the covering surgical team
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Pilot CSEWSOrder set Implemented spelling out nursing orders - regardingvital signs & notification
Nursing/Tech education
SBAR Communication
Specialized charting sheets for CSEWS - they would be
turned in at the end of each shift to nursing leadership
Cards for techs highlighting abnormal vitals in red - immediatenotification to Nurse
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Results, N= 224 Patients
Random Audit 80 CSEWS160 times CSEWS => 3 DURING THIS TIME PERIOD
5.16 was the Average Post op Day of Elevated CSEWS
2.38 was the average number of Days on 4 NW when elevatedCSEWS occurred
66.25% elevated CSEWS - Day shift
52.5% - scored =>3
33.75% - scored =>4
13.75% - scored =>5
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reasons for elevated CSEWS:* Tachycardia - 85% had a HR 101-119* Oxygen support - 78% @ 1-4 L/nc* Hypertension - 32% had SBP 136-150* Tachypnea - 72% had RR of 21-25
68% patients received treatment for their elevatedCSEWS
1Bounce back to the SICU during pilot period, pt.did have a positive CSEWS
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Cardiac Surgery Early Warning Score -
Version II
Score 3 2 1 0 1 2 3
SBP 165
HR 140
RR 30
Resp.
Support
>6L/NC
> 50%FIO2
5-6L/NC40-50%FIO2
3-4L/NCRA-
2L/NC
LOC Alert
Respond toVoice -newConfusionR
estless
Respondto Pain
Unres-ponsive
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Preliminary results of Version II CSEWS
5 Bounce backs * 1V-Fib arrest - survived and was D/C
First Two Quarters of FY 2012 - No Mortality fromBounce Backs -
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Where are we going from here withCSEWS
Validate the tool
?? Use for this tool in assessing readiness totransfer from the SICU to the floor
Challenges with hardwiring this into nursing practiceon the cardiac step down unit.