Retrospective review of the Modified Early Warning Score in critically ill surgical inpatients at a Canadian Hospital

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1 Retrospective review of the Modified Early Warning Score in critically ill surgical inpatients at a Canadian Hospital Alisha Mills PGY 4 General Surgery Northern Ontario School of Medicine S

2 Disclosures S I have no financial/personal relationships to disclose

3 Background S Thunder Bay Regional Health Sciences Centre has a well established Medical Emergency Team (MET). S MET activated by single parameter track and trigger systems S Team consists of RN and MD, acts as Code Prevention Team

4 MET Calling Criteria Pt shows signs of acute change in: S S S S S Airway: S Threatened airway or Stridor or Excessive Secretions Breathing: S RR <8 or >30 or Distressed breathing or Sats <90% on 50% oxygen or 6LNC Circulation: S SBP <90 or >200 or decreased >40mmHg or HR <40 or >130 or Urine output <100mL in 4 hrs except dialysis pts Neurological: S Decreased LOC or GCS decreased greater than 2 Worried: S Serious concern about the pt

5 Background Critical Care Medicine, Dec 2009, Vol 37, No. 12, pp

6 Background S Is there a way to help multidisciplinary teams identify patients at risk of catastrophic deterioration? S Would a scoring system help decrease Code Blue events and catastrophic deterioration in surgical patients?

7 Modified Early Warning Score (MEWS) S Quick bedside tool S Uses already recorded parameters S Highlights patients at risk of deterioration S Allows for more vigorous monitoring or transfer to higher level of care before critical decline

8 MEWS HR < >129 Temp < >38.4 SBP < >199 RR < >29 LOC Alert Voice Pain Unrespo nsive

9 Potential Impact of MEWS S Gardner-Thorpe et al., S Assessed in 334 surgical patients and colorectal patients S 75% of patients transferred to ICU or stepdown had MEWS >4 S NNT 5 S Maupin et al., S Hospital-wide implementation of MEWS in a hospital in Cincinnati S 50% decrease in Code Blues S 200% increase in RRT calls Ann R Coll Surg Engl 2006;88: Jt Comm J Qual Patient Saf 2009;35(12):

10 Our Question S In surgical inpatients who were seen by the Medical Emergency Team (MET) and/or had Code Blue events: S What was their MEWS at the time of the event and in the preceding 48hrs? S Can this information be used to identify those patients who would have benefited from earlier intervention by MET?

11 Methods S Feasibility study, retrospective review of Medical Emergency Team calls from July 1, 2010 to July 1, 2011 to inpatients on surgical floors (3A, 3B) S Retrospective review of Code Blue calls from July 1, 2010 to July 1, 2011 for inpatients on surgical floors (3A, 3B, 3C, 3CN) S Assessment of MEWS at time of MET call and in 48hrs prior to MET call S Assessed 179 patients with 218 MET or Code Blue calls

12 Primary Outcome S MEWS at time of MET call and/or Code Blue event

13 Secondary Outcomes S Time between MEWS 5 and MET call S 30-day in-hospital mortality rate S Number of ICU admissions resulting from MET calls

14 Demographic Information Admitting Service Ortho General Surgery Hospitalist Family Med Gyne Urology Other

15 Indications for MET Call 40% 30% 20% 10% 0% % MET Calls % MET Calls

16 Results Sensitivity Specificity PPV NPV

17 MEWS Results MET MEWS Disposition 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% < 5 5 Missing Vitals 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% < 5 5 Ward ICU Deceased

18 Time between MEWS 5 and MET 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Time: 4-12 hrs Time: hrs %

19 Results at MET call Variable MEWS <5 MEWS 5 Test P-value Age (median and range) Gender (male:female) 30-day mortality Disposition to ICU LOS (median and range) 72 (20-97) 76 (31-95) Mann-Whitney U test :57 50:49 Chi-square % 30.43% Chi-square % 38.38% Chi-square < (1-103) 15 (2-178) Mann-Whitney U test 0.003

20 Effect of MEWS in 4-12 hrs preceding MET call Variable MEWS <5 MEWS 5 Test P-value Age (median and range) 76 (20-97) 74 (31-93) Mann-Whitney U test Gender (male:female) 30-day mortality Disposition to ICU LOS (median and range) 66:85 4:3 Chi-square % 41.86% Chi-square < % 42.86% Chi-square (1-157) 17 (2-73) Mann-Whitney U test 0.456

21

22 Results S Less then half of MET calls reached MEWS calling criteria S Many patients exhibit signs of clinical deterioration before being seen by MET in the 4-48 hours prior to call S Statistically significant increase in disposition to ICU, 30- day in-hospital mortality and length of hospital stay with MEWS 5

23 Conclusions S Despite a well-developed MET team, many patient exhibit vital sign abnormalities suggestive of critical deterioration prior to their assessment by MET S MEWS identifies patients at risk of clinical deterioration prior to assessment by MET S Implementation of MEWS into pre-existing EMR could be used to identify patients at risk of deterioration

24 Limitations S Retrospective chart review S Depended on electronically charted vital signs S Level of consciousness not consistently charted S Mostly surgical inpatients

25 Future Directions of Research S Prospective hospital-wide implementation trial at Thunder Bay Regional Health Sciences Centre S MEWS will be implemented into EMR, will be automatically calculated S Algorithm for increasing MEWS will include alerting MRP and increased monitoring

26 Many Thanks To: S Dr. S. Zaki Ahmed S Dr. Alison Fox-Robichaud S Dr. Heather MacLeod S The Method Centre, Ottawa

27 Questions? S

28 References S S S S S Campello G et al., Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs. Crit Care Medicine Dec 2009, 37(12): Ludikhuize J et al., Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care 2012 epub /jcrc Subbe CP, Kruger M, Rutherford P, Gemmel L., Validation of a modified early warning score in medical admissions. Q J Med 2001;94: Gardner-Thorpe K et al., The value of modified early warning score (MEWS) in surgical inpatients: a prospective observational study. Ann R Coll Surg l 2006;88: Maupin JM, Roth DJ, Krapes RN., Use of modified early warning score decreases code blue events. Jt Comm J Qual Patient Saf 2009;35(12):

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