Solution Title: Predicting Care Using Informatics/MEWS (Modified Early Warning System)

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1 Organization: Peninsula Regional Medical Center Solution Title: Predicting Care Using Informatics/MEWS (Modified Early Warning System) Program/Project Description, including Goals: Problem: As stated in Institute for Healthcare Improvement reasons for establishing a Rapid Response Team, there is a large amount of variability in both quality of care and the safety of patients in health care today. This variability is evident in hospital mortality rates. A review of the literature reveals that there are three main systemic issues that contribute to the problem: Failures in planning (includes assessments, treatments, goals) Failure to communicate (patient to staff, staff to staff, staff to physician, etc.) Failure to recognize deteriorating patient s condition These fundamental problems can often lead to a failure to rescue. Patients, whose condition deteriorates acutely while hospitalized, often exhibit warning signs (such as abnormal vital signs) in the hours before experiencing adverse clinical outcomes. Opportunity: To reduce the number of code blues and improve patient safety in our med/surg patient population by evaluation, modification and piloting a MEWS scoring process. The MEWS scoring process addresses all three problems that can lead to a patient s deterioration. Analysis Code Blue data collected over several years and routinely shared during our Code Blue Committee meeting, indicated there were a significant number of Code Blues in our Med/Surg areas. There were several campaigns initiative aimed at earlier recognition of patient s status change and earlier intervention using Rapid Response calls. There was some success, but it was felt there needed to be more done to improve patient s safety. We chose to focus our efforts and pilot the MEWS initiative on 5East, a medical floor and the patient care area with the highest number of code blues. By implementation of our pilot program, we had seen a steady increase in code blues house wide and on 5East. As a result, we used the first 5 months of as our pre-mews time frame. Traditionally, the data shared in our Code Blue Committee was measured in per discharges and in percentage of total codes compared to non-med/surg calls (critical care and procedural areas). When we began to analyze our MEWS data, we realized we needed a standard that was more representative of patient days vs patient discharges (5 East pre- MEWS data displayed below is per patient days).

2 CB/ Pt. Days 5E RR/ Pt. Days 5E CB/ Pt. Days RR/ Pt. Days Linear (CB/ Pt. Days) Linear (RR/ Pt. Days) What is MEWS (Modified Early Warning System); A scoring system that identifies high-risk patients using vital signs Identifies patients likely to deteriorate so additional steps can be implemented to avert further decline How Does MEWS Work: Key Points: Based on vital sign parameters: - Heart Rate - Blood Pressure - Respiratory Rate - Oxygen Saturation - Temperature Each parameter is given a score - Normal parameter = - Abnormal parameters =, or 3 Detects early signs of deterioration so changes can be acted upon appropriately Early warning scores are a tool to bring attention to vital signs of deterioration Physiological deterioration usually precedes critical illness It is important to recognize and intervene when patients have abnormal vital signs

3 Early effective intervention can improve patient s outcome and use of intensive care resources Abnormal early warning scores triggers a call to critical care outreach teams, who are there to help manage deteriorating patients What is a Rapid Response Team: The purpose of the Rapid Response Team is to prevent medical emergencies (Code Blue events) when healthcare staff recognize potential problems and to use a proactive approach with the assistance of trained expert staff available at the bedside The Rapid Response team will obtain clinical data and perform interventions based on approved protocols and advanced life support guidelines What We Did: Assembled a Multidisciplinary Workgroup - Code Blue Team: reports to PI council: board level team sanctioned the development and implementation of MEWS Care Alert for notification of MEWS score > Collected and Analyzed Data - HBI, EXCEL, ACCESS PREMIER Quality Advisor Presented to JPP, MEC and Nursing Leadership Identified Pilot Area, 5 East with Implementation date of June, Demonstration project to validate tool and assess process Goals of MEWS Pilot Proactive Clinical Goals of MEWS Pilot: Reduce number of Code Blues Reduce Mortality (post Code Blue event) Increase number of Rapid Responses Non-Clinical Goals of MEWS Pilot: Determine impact on Staff Patient population triggering Alerts (electronic staff notifications of MEWS occurrence) Peak days and times of Alerts Do the alerts impact LOS/Cost Testing the Alert and its Impact on Work: Care alert to core PI team and charge nurse ( or print)

4 Care Alert would go to Care Organizer, Care Board, Charge Nurse and Printer with full detail alert parameters Nurse Spec did concurrent review of MEWS process Code Blue team leaders: Director of Respiratory Care and CMIO assessed all MEWS alerts Daily Meetings to evaluate tool and process around the tool MEWS Scoring Parameters and MEWS Score Action Plan 3 3 Pulse Rate < >/=3 (bpm) Respiratory < >/= 3 rate Temperature < >3.5 Systolic BP < >/= OSat <

5 Staff Education (Nursing, Ancillary and Physician): Expectations Netlearning Story Boards Articles in department publications Presentation to staff at department meetings Go-Live Support Accurate and timely vital sign documentation Increase in RR s expected and highlighted increased work Reduction in non-critical care codes Reduction in transfers Increase in bedside monitoring Call an RR even if the patient LOOKS GOOD for MEWS greater than 5 Results: Code Blues 5 East MEWS 9 Day Trial RR 5 East MEWS 9 Day Trial Code Blues Per Patient Days Code RR Per Patient Days

6 9 Months Code Blues 5 East MEWS 9 Months RR 5 East MEWS 9 Months Code Blues Per Patient Days Code RR Per Patient Days Months Code Blues 5 East MEWS Months RR 5 East MEWS Months Code Blues Per Patient Days Code RR Per Patient Days

7 Summary: MEWS is now LIVE on all Patient Care Services areas as well as West (CSSA). Although all areas in Patient Care Services are LIVE, the go-lives for these areas were staggered. Below are the results for house wide Code Blues and Rapid Responses: MEWS Go-Live dates: 5E (/); S, 3L, 5L (//); W, 5S (3/3); 5W (/3) Code Blues Events House Wide have Decreased Code Blues // through /3/3 Code Blues per Patient days Linear (Code Blues per Patient days) Rapid Response Calls House Wide have Increased Rapid Response Calls // through /3/3 Rapid Response calls per Patient Days Linear (Rapid Response calls per Patient Days)

8 Summary (cont.): Enhanced bedside assessment using existing tools: low cost/high yield Improved team approach to bedside care with improved communication between ancillaries Reduced bad outcomes using a standard predictive model with existing functionality Lowered cost by improving efficiency and management of current data reducing transfers and codes Enhanced already existing CUSP initiative at the bedside In the first 9 months, we have seen a % reduction of Med/Surg Code Blues Projected, potential healthcare savings of 3. million dollars by reducing Med/Surg code blues by % (our 9 month realization) month results indicate a 7% reduction in Code Blues on 5 East Pilot Area month results indicate a 7% increase in Rapid Response Calls on 5 East Pilot area MEWS Core Team: Innovation: Deborah Clayton, MSN, RN, PCCN, Clinical Nurse Specialist Cindy Hurley, MSN, RN, CMSRN, Clinical Nurse Specialist Carol Moran, RN, BSN, Clinical Analyst John Morcom, RRT, Director Respiratory Services Christopher Snyder, DO, Chief Medical Information Officer, Hospitalist Amy Thamert, MEd, RRT, Clinical Analyst Ann Turner RN, MS, CCRN, CCNS, Clinical Nurse Specialist The MEWS system is not new, it have been used in other facilities to some degree in both the United States and other countries. The adoption of this process has been difficult as many institutions have made this a manual calculation process. The process at PRMC is electronic and not only has electronic calculation, but electronic notification to the bedside caregiver and the charge nurse leading the team. It is also an aid to documenting the MEWS score through the electronic notification system. This electronic process uses a patient care procedure already in place which reduces the impact on the staff caring for the patient. This process improves communication between the CNA and RN, the RN and the Charge Nurse and the Charge Nurse with the patient s physician. Contact: Chris Snyder D.O. / John Morcom RRT Phone: Chris Snyder D.O / John Morcom RRT -9-9

9 Predicting Care Using Informatics Chris Snyder, D.O., John Morcom, RRT, Deborah Clayton, MSN, RN, PCCN, Cindy Hurley, MSN, RN, CMSRN Introduction MEWS Scoring from Evidence 3 Pulse Rate (bpm) < Respiratory rate < >3.5 Code Blue: An emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a 'code team') to rush to the specific location and begin immediate resuscitative efforts. Rapid Response Team The purpose of the Rapid Response Team (RRT) is to prevent medical emergencies (Code Blue events) when healthcare staff recognize potential problems and to use a proactive approach with the assistance of trained expert staff available at the bedside. The RRT will obtain clinical data and perform interventions based on approved protocols and advanced life support guidelines. Standard Protocol for MEWS Score at Bedside Temperature Systolic BP OSat <7 < >3 >/= 3 >/= < Pilot Results What is MEWS? PRMC Baseline analysis -: pre-mews with NEW RR process Code Blues per patient days Key Points.5 Increased awareness Set new team goals Education with Net Learning New posters available Protocols updated Silent RR Hospitalist/PA responding to RR Initiative for RR Lactate and transfer to ICU if higher level of care needed Future Plans Determine impact on Staff Patient population triggering Alerts Peak days and times of the alerts Do the alerts impact LOS/Cost 9. Consecutive Months without a Code Blue 7 of 9 Months without a Code Blue Code Blues per patient days Rapid Response Calls per patient days (7% Decrease) (7% Increase) Goals and Process Cost of a cardiac arrest in St. Cloud, Minnesota study - Code Blue survivors cost, additional dollars - Code Blue non-survivors cost 3,39 additional dollars - We have Med/Surg units at PRMC: - are live on MEWS 3. million dollars potential savings if we prevent all code blues on Med/Surg areas alone using data In 9 months, we have seen a 7% reduction of Med/Surg code blues. Already an estimated.3 million dollar savings Optimized bedside assessment leveraging existing clinical data: low cost high yield Improved team approach to bedside care with accelerated information exchange between ancillaries Reduced poor outcomes using a standard prediction tool leveraging existing informatics functionality Lowered cost by enhancing awareness and management of current electronic patient data ultimately reducing transfers and code blues Enhanced already existing CUSP initiative at the bedside Summary of 9 Months Impact on 5East Non-Clinical Goals of MEWS Pilot: 5. What we DID! Reduce number of Code Blue Reduce Mortality (post Code Blue event) Increase number of Rapid Responses Early warning scores are a tool to bring attention to vital signs of deterioration Physiological deterioration usually precedes critical illness It is important to recognize and intervene when patients have abnormal vital signs Early effective intervention can improve patient outcome and use of intensive care resources Abnormal early warning scores trigger a call to critical care outreach teams, who are there to help manage deteriorating patients Rapid Response Calls per patient days (9% Increase) 5 Clinical Goals of MEWS Pilot: Results of 5 East MEWS 9 Day Trial A scoring system that identifies high-risk patients using vital signs Identifies patients likely to deteriorate so additional steps can be implemented to avert further decline Eliminating Code Blues Yields Results Assembled a Multidisciplinary Workgroup - Code Blue Team: reports to PI council: board level team sanctioned the development and implementation of MEWS Care Alert for notification of MEWS score > Collected and Analyzed Data - HBI, EXCEL, ACCESS, PREMIER Quality Advisor Presented Data to JPP, MEC and Nursing Leadership Began Policy / Procedure & Net Learning Module Identified Pilot Area, 5E Demonstration project to validate tool and assess process Team Medical Director of CC Director of Respiratory Care CMIO/CQO Director of Cardiology Nursing Leadership Pharm D Radiology Director Nursing Supervisors and Bed Coordinators OPI and CPI Directors and Analysts East Pilot area over one year (5 Months) Code Blues per patient days (7% Decrease) Rapid Response Calls per patient days (5% Increase) House-wide Month Results Results House-wide with MEWS Deployed to Areas: ( Months) Code Blues per patient days (% Decrease).... References Rapid Response Calls per patient days (55% Increase) PEWS: pediatric unit deployment Emergency room: triage EWS and admission assessment EWS PACU: placement post-op EWS MEOWS: obstetrical post-op Integrated vital signs monitors for accelerated vital sign entry and bedside MEWS Level One Cardiac Arrest Centers are Clinically and Cost Effective Keith G. Lurie, Pam Schnettler, Janet Steinkamp, Joe Helli, Roberta Basol, Scott Davis St. Cloud Hospital, St. Cloud, MN. ACT Health Policy: Modified Early Warning Scores (7) retrieved // University of Newcastle, UK () Early Warning Scores retrieved // Automated Modified Early Warning System (MEWS): Early Detection of Patient Deterioration retrieved // dout%9-9.pdf Early Warning Scoring System Proactively Identified Patients at Risk of Deterioration Leading to Fewer Cardiopulmonary Emergencies and Deaths (9) Agency for Healthcare Research and Quality retrieved // Template provided by: postersresearch.com

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