Early Warning Systems: Scorecards That Save Lives

For the past few years, the Institute for Healthcare Improvement (IHI) has challenged hospitals across the United States to reduce cardiac arrests and other sudden, life-threatening events in patients on general medical floors by implementing a system of Rapid Response Teams. Such a system involves empowering staff nurses, and in a small but growing number of hospitals a family member, to summon a designated group of clinicians to a patient’s bedside to critically and quickly evaluate signs of a worsening condition. Steps can then be taken to head off the worst, including transferring the patient to an intensive care unit if necessary.

As part of IHI’s 100,000 Lives Campaign some 1,500 hospitals are now actively using and/or implementing Rapid Response Teams. Cardiac arrest rates, mortality rates, and lengths of stay in the intensive care unit (ICU) are dropping, and hospitals with Rapid Response Teams are moving their cultures toward a team-based approach to clinically challenging situations.

Currently, most Rapid Response Teams in the United States are triggered by one parameter at a time, and that parameter often represents a significant change in a particular vital sign. For example, a significant change in blood pressure might trigger a call to the Rapid Response Team, or a significant change in skin color might trigger a call. In some cases, a general feeling that something is not right might lead to a call. Many teams report that approximately 40 percent of calls to the Rapid Response Team are generated because the caller feels there is “something just not right” with the patient.

While a single-parameter approach has been effective, what if organizations could identify at-risk patients even before a significant vital sign change? What if a system were created that could respond to multiple parameters at the same time and identify at-risk patients at the first sign of a subtle change in vital signs? Such an Early Warning Scoring System (EWSS), experts say, could yield even more benefits for patients and hospitals by identifying deteriorating patients even earlier.

Kathy Duncan, RN, faculty expert on Rapid Response Teams for IHI, says an EWSS can add another layer of early detection to the Rapid Response Team system. “We want to encourage recognition of high-risk patients as soon as possible. The Rapid Response Team cannot be effective if it is not called to the patient bedside in time. An EWSS can prompt nurses to make that call even earlier,” says Duncan.
The idea of an Early Warning Scoring System is very new within the United States; however, in the United Kingdom this concept is being used with success in many hospitals. Ysbyty Glan Clwyd (YGC), located in Rhyl, Denbighshire, in central North Wales, is one such facility. YGC is a 900-bed acute care hospital that serves as headquarters of the Conwy & Denbighshire National Health Service (NHS) Trust. The Trust is part of the IHI’s Safer Patients Initiative (SPI), conducted in collaboration with The Health Foundation, an independent charity working to improve the quality of health care in the UK. SPI is actively working to improve the quality and safety of health care in the UK by encouraging the uptake and spread of best practices.
Like many organizations, Ysbyty Glan Clwyd implemented a Rapid Response Team, which they also refer to as an “outreach team,” to improve how quickly patients experiencing a sudden decline receive clinical attention, get admitted to intensive care if needed, and are able to leave the ICU because of a better way to monitor patients throughout the hospital. The team is made up of a dedicated part-time senior ICU sister (the UK’s equivalent of a unit leader) and a rotating senior ICU staff nurse.
After creating the outreach team, the organization found that not all “at-risk” patients were being identified. Nurses didn’t have a complete set of criteria to identify a failing patient early and trigger a call to the team. “We found that nurses were not calling the team, and we needed to establish some clear criteria that would prompt the nurses to make the call and take action to address the patient’s needs,” says Delyth Williams, ICU and outreach sister for Ysbyty Glan Clwyd. “Just as the outreach team was not effective by itself, one of our medical wards had tried to introduce a set of early warning criteria for nurses to use before we had the outreach team in place; that, too, failed.” So, the challenge became one of taking that same Modified Early Warning System (or MEWS) and marrying it to the outreach team.
How the MEWS Works
When a nurse at Ysbyty Glan Clwyd takes a patient’s vital signs and records them on the patient’s chart (see Figure 1 below), if any one of the following six vital signs falls in to a red zone, the nurse is prompted to determine a MEWS score for the patient:
  • Respiratory rate
  • Heart rate
  • Systolic blood pressure
  • Conscious level
  • Temperature
  • Hourly urine output (for previous 2 hours)

Determining a MEWS score involves assigning a number between 0 and 3 to each of the six vital signs (see Figure 2 below). For example, if a patient’s systolic blood pressure is between 71 and 80, or if it is more than 200, the nurse would assign that vital sign a score of 2. The sum of the scores of the six vital signs yields the patient’s total MEWS score. If the total score is 4 or greater, this prompts the nurse to call the patient’s physician and also the organization’s outreach team.
“We try to let the doctor and the patient’s nurse take the lead in this response system, all the while the outreach team contributes to the medical assessment, presents recommendations, and offers support to both the nurse and doctor,” says Williams. Although similar to Rapid Response Teams in the United States, Ysbyty Glan Clwyd’s outreach team is designed to play a more consultative role. “Because the outreach team is small, we cannot take over clinically every time we are called. Not only would we spread ourselves too thin, but it wouldn’t empower the participation of the doctor and nurse so that everyone works together to address the patient’s needs,” says Williams.
The beauty of Ysbyty Glan Clwyd’s system, say its proponents, is that the MEWS logically fits within processes that nurses are already doing. “Nurses are taking vital signs anyway, and the color-banded patient chart gives a visual cue as to when to calculate a MEWS score, helping prompt a faster call to the outreach team,” says Pat Anderton, senior staff nurse of the ICU outreach team. “We redesigned our patient charts to highlight those visual cues.”

Educating Staff on the System 
To help familiarize the staff with MEWS, the outreach team developed laminated pocket cards, with the MEWS algorithm on the back, for all the ward nurses. Delyth Williams and Pat Anderton also attended staff meetings and education sessions and discussed the purpose of the outreach team, the importance of an Early Warning Scoring System, and how the system would work. The team also participated in monthly study days, in which both registered nurses and other nurses receive training on a variety of topics. “We came to these study days and talked about the outreach team and the Early Warning Scoring System, and we also provided training on patient assessment skills,” says Williams. Such skills included how to effectively assess a patient’s airway, breathing, and circulation.
“Providing education in basic assessment skills is critical to the success of the MEWS, because the system can yield false positives and negatives at times and strong assessment skills can help identify those situations,” says Williams. For example, a patient whose vital signs normally fall outside of the assigned parameters may trigger a score that leads to a call to the outreach team when he or she is not that sick. To ensure the MEWS protocol is regularly followed, nurses must always notify the outreach team when a trigger score is reached. However, if the nurse has justifiable reasons to hold off having the doctor and outreach team come to the patient bedside, he or she is empowered to make that decision.
Conversely, a patient who is sick may not trigger a score if his or her vital signs do not fall within the predetermined high-risk values. “We have found that, with experience and improved assessment skills, the ward nurses are able to recognize that a patient is unwell, although the nurse can’t put his or her finger on why,” says Williams. Therefore, the outreach team encourages ward staff to contact the team if the patient gives “cause for concern,” with or without a trigger score. “It is essential that outreach team members are non-judgmental and respectful of the ward nurses’ concerns. Making them feel foolish for potentially inappropriate referrals could prevent ward staff members from using the team in the future, therefore putting their patients at risk,” says Williams.
Gaining Staff Support
Initially, the nurses and doctors at Ysbyty Glan Clwyd were less than enthusiastic about the MEWS and outreach team. “They often considered us the enemy and, in some cases, they thought we were just interfering,” says Williams. To overcome this resistance, the outreach team frequently visited every ward, asking to see anyone with a high MEWS score. “Your face gets known after awhile, and people realize you are there to help, not take over their job. As more and more nurses saw the benefits to using the scoring system and having the team as a resource, they began using us more often,” says Anderton. “We also carefully considered the personnel who would be on the team. You need someone who can act as a mediator and educate without stepping on toes. Both Delyth and I serve in this capacity.”
Measuring Success
Ysbyty Glan Clwyd began examining the success of the MEWS and outreach team by using the IHI’s critical care team measures. “Much to our dismay, we discovered that people weren’t calling the team as much as they should, and nurses weren’t recording respiratory rates or documenting MEWS scores, nor were they reacting to trigger scores,” says Williams.
To address this, the organization began conducting rapid-cycle Plan-Do-Study-Act (PDSA) tests of change.
The organization began with one ward and did weekly chart audits using a compliance checklist (see figure below). “When the weekly chart audits weren’t sufficient to yield change, we began picking five random charts to audit daily and provided immediate education to improve compliance,” says Williams. “Within a week, that first ward was compliant. We then moved to another ward until all the wards were compliant with the process.” By moving to daily chart audits, the organization was able to call attention to the MEWS process and encourage nurses to document MEWs scores and react to trigger scores. 
Ysbyty Glan Clwyd has continued its auditing process to ensure that things don’t slip back the way they were. “We have shifted auditing responsibility to a designated nurse on each ward. The outreach team does monthly spot checks to ensure that standards are being maintained,” says Williams. “If we had to do the implementation piece of this program over again, we would have done a pilot program and then rolled it out housewide. That could have saved us some time, energy, and frustration,” says Williams.
Achieving Results
Now that the nurses and doctors across the organization are using the MEWS and outreach team, the organization has seen an increase in the number of calls to the team and a decrease in the number of cardiac arrests. Since March 2005, the organization has cut its crash call rate in half, going from approximately eight crash calls per 1,000 discharges to four.
The MEWS and outreach team have also improved the response time to deteriorating patients. “For example, historically, if a junior doctor needed assistance in assessing and responding to a patient, there were no other options but to call up the ranks. This was typically a slow process. With the MEWS and outreach team working together, we can get senior personnel to the scene much faster. The system enables ward nurses to contact senior doctors and get the patient the assistance he or she needs,” says Williams.
Other Organizations Pursuing Early Warning Scoring Systems
While the concept and components of an Early Warning Scoring System are not yet being widely adopted in the United States, the tools and resources to implement EWSS (as part of the Rapid Response Teams intervention) are now part of IHI’s 5 Million Lives Campaign, the follow-on to the 100,000 Lives Campaign (see the updated How-to Guide for Rapid Response Teams).
One organization ahead of the curve is the Order of Saint Francis (OSF) Saint Joseph’s Medical Center, a 154-bed acute care hospital located in Bloomington, Illinois, and part of OSF Healthcare System, a multi-state health care system operating facilities in Illinois and Michigan. OSF Saint Joseph’s has developed an automated EWSS. When nurses take patient vital signs, they enter them into the patient’s electronic medical record. Those vital signs automatically populate a data warehouse that supports a patient risk tool that includes early warning scores for the previous four days as well as patient lab values for the last eight hours, key medications, and so forth. The patient risk tool also shows graphs of patient vitals for the past 48 hours. “The report gives a snapshot of where the patient is at,” says John Whittington, MD, Director of Knowledge Management and Patient Safety Officer for OSF Healthcare System. At a predetermined time, the computer prints out any patient risk reports for the supervisory nurse to review. He or she looks at each report and determines whether to call the attending physician, alert the Rapid Response Team, or continue to monitor the patient, depending on what the report shows.
While the OSF St. Joseph’s system is automated, Whittington cautions that organizations should not let a lack of technology stop them from creating some kind of EWSS. “The most important thing is to identify patients earlier and have a structure in place to respond to that identification.”
A Call to Action
While the Rapid Response Team plays a critical role in saving patients’ lives, an Early Warning Scoring System can help organizations take the next step, identifying at-risk patients sooner and saving more lives. “IHI will be encouraging organizations to investigate and implement a multiparameter EWSS as part of their Rapid Response Team effort,” says the 5 Million Lives Campaign’s Kathy Duncan. “Such a system can help build reliability into the Rapid Response Team system and attempt to or try to guarantee that no at-risk patients are missed.”
“There is no ‘perfect way’ to do this,” continues Duncan. “Organizations should consider how they can identify at-risk patients sooner and develop processes that are appropriate for their staff, patients, and culture. This may involve piloting concepts before rolling them out housewide and using rapid cycle plan-do-study-act (PDSA) tests of change to help drive improvement. The goal of these efforts should be to determine how an EWSS can be incorporated into the nursing workflow.” 
The work in creating an EWSS will not necessarily be easy, and the path to success may not be straight. However, organizations that can implement a system that reliably identifies deteriorating patients early and responds to their needs quickly can help reduce patient mortality and save lives.
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