from reactive to proactive - acpnj

From Reactive to ProactiveTO 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’GaraYasmin AhmedRichard 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 activationB. 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 scoreNEWS 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

Score: 0-4 = Low Risk

46%

Score: 5-6 = Moderate Risk

21%

Score: ≥7 = High Risk33%

Figure 1. Risk categories based on NEWS at the time of RRT

Males38%

Score: 0-4 = Low Risk

48%

Score: 5-6 = Moderate Risk

21%

Score: ≥7 = High Risk

31%

Females62%

Figure 2. Distribution of Female RRT cases into different risk categories

Females 62% Score: 0-4 =

Low Risk44%

Score: 5-6 = Moderate

Risk20%

Score: ≥7 = High Risk

36%

Males38%

Figure 3. Distribution of Male RRT cases into different risk categories

Disposition

Death0%

Maintained81%

Transfer to Hospice1%

Transfer to ICU/CCU6%

Transferred to Non-ICU Higher Level of Care

12%

Death0%

Maintained68%

Transfer to ICU/CCU25%

Transferred to Non-ICU Higher Level of

Care 7%

Death3%

Maintained49%

Transfer to Hospice

2%

Transfer to ICU/CCU

29%

Transferred to Non-ICU

Higher Level of Care 17%

Low risk Moderate risk High risk

Results: Age and Risk Categories

Age ≥6558%

Score: 0-4 = Low Risk

55%

Score: 5-6 = Moderate Risk16%

Score: ≥7 = High Risk

29%

Age ≤64 42%

Figure 4. Distribution of RRT cases Age ≤64 years old into different risk categories Age ≤6442% Score: 0-4 =

Low Risk40%

Score: 5-6 = Moderate Risk

24%

Score: ≥7 = High Risk

36%

Age ≥6558%

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.

Fifty percent of patients who had RRTs showed initial signs of deterioration 4 hours prior to the actual RRT.

Hours since RRT

No. of Patients

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 co-morbidities.

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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