Identify Early Warning Signs Of Change In Patient Deterioration

 Medpoint:Identify Early Warning Signs Of Change In Patient Deterioration

Identify Early Warning is not uncommon for hospitalized patients to exhibit early warning signs before deteriorating. The key to optimal outcomes is recognition of these warning signs followed by an appropriate and timely response. Have you ever called the Rapid Response Team (RRT)? What triggered your call? In most U.S. hospitals, a single warning sign, such as a sudden drop in blood pressure, may trigger a call.

 

Very often, the feeling that “something is just not right” prompts the call. But is there a way to quantify what might be going wrong in order to address the problem earlier?

Enter the Early Warning Scoring System, or EWSS, which can encourage early intervention, timely transfer to a higher level of care and prevention of codes. EWSS originated in the United Kingdom. Over the last few years, U.S. hospitals have begun to utilize the tool here in the states. Implementing EWSS “adds another layer of early detection to the RRT system” (IHI, n.d.) and allows the healthcare team to intervene earlier.

 

One widely used version is the Modified Early Warning System (MEWS). Healthcare personnel enter vital signs on a chart form that has red-shaded zones to identify findings outside the normal range for six vital signs, namely: Respiratory rate, heart rate, systolic blood pressure, level of consciousness, temperature and hourly urinary output.

 

When any one of these signs falls into a red zone, the nurse determines a MEWS score for the patient, assigning a number between 0-3 to each of the six vital signs (as shown in the MEWS algorithm chart, below). The nurse then adds the individual scores for a total MEWS score. If the total score is 4 or higher, the nurse is to call the patient’s provider and alert the RRT

 

Identifying Patient Deterioration

Early identification of patient deterioration is key to intervening for serious conditions like sepsis. However, early indicators can present subtly, making detection difficult and subjective.

Adding complexity, there are often several signs or symptoms that—when they present together—can indicate the onset of a condition far more serious than what may be diagnosed by just looking at

one of those signs or symptoms individually. Connecting the dots to see the complete picture becomes vital to enabling faster, more informed decisions on providing care.

 

·        Patient acuity levels are rising, but staff-to-patient ratios generally are not.

·        A wider range of staff members, with varying levels of clinical training and experience, are taking patient vital signs.

·        Some important indicators of deterioration are not consistently part of routine vitals acquisition (e.g., respiratory rate, Is & Os, level of consciousness).

·        Vitals are not typically monitored continuously in this setting. Rather, they are spot-checked during rounds every four to six hours, depending on the patient. Time spent assessing the patient during those visits to the bedside becomes critical in collecting comprehensive information and making it actionable so that clinicians can react quickly in order to impact patient outcomes.

MEWS Chart

 

Hospitals’ protocols and procedures vary in the use of EWSS. Some use the RRT for consultation as well as intervention. Other institutions may not utilize all six of the MEWS parameters, or may modify the tool for specific patient populations such as pediatrics or obstetrics

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In some settings, vital signs entered into the EMR “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 nurse evaluates these reports and decides whether to call the attending physician, alert the RRT, or continue to monitor the patient (IHI, n.d.). Another teaching hospital color codes their levels of EWSS scores (Duncan, et al., 2012):

 

• Green = normal

• Yellow requires the charge nurse to reassess.

• Orange requires the charge nurse to reassess and notify the resident.

• Red requires that the nurse notify the RRT and resident.

• Orange or red requires resident-to-resident handoff reporting at the bedside.

Use these early warning signs to detect patient deterioration and gain the benefits of early intervention.

 

RN.com now offers a new course entitled: The Chain of Command Protects Your Patients and You. This 2 contact hour activity reviews some clinical examples of common risk-for-deterioration scenarios and early warning signs that should be acted upon immediately, and suggests ways in which the nurse can successfully navigate the chain of command to prioritize patient safety.

Importance

• Deterioration in a patient’s clinical condition frequently occurs over several hours before a critical event, providing hospital staff with a potential window of opportunity for intervention if detection of signs and symptoms occurs early.
• Evidence-based practices to address early clinical deterioration include implementation of a rapid response team (RRT).
• Quickly providing clinical caregivers with intelligently filtered information regarding specific patient conditions at the bedside can improve clinical decision support.
• To aid in early detection, track and trigger methods (TTMs) assign a number score to specific signs and symptoms the patient may be either exhibiting or verbalizing.

The use of early warning scores—especially automated scores, as opposed to manual calculations—has been shown to improve effectiveness.

• Nurses who used analytic decision-making activated Rapid Response Teams (RRTs) about twice as much as those using their intuition.²
• Modified Early Warning Score (MEWS) calculations three times per day have been shown to result in two times as many RRT calls and decrease the number of ICU transfers by 40%.³
• A pediatric unit’s implementation of a Pediatric Early Warning Score (PEWS) resulted in 85% of children with PEWS ≥3 improving their condition within 24 hours of a rapid medical intervention.⁴

 

EARLIER WARNING SIGNS OF DETERIOARTION IN CLINICAL CONDITIONS

CLINICAL CONDITIONS	EARLIER  WARNINGS	MANAGEMENT
MI(Myocardial Infarction)	·        Severe chest pain ·        Pain in back radiate to L arm ·        Excessive/ Breathlessness + in some cases	·        Complete bed rest,O2 inhalation st&sos maintain BP Chart/TPR
CVA – Cerabrovascular Accident(Stroke)	·        Weakness upper / lower extremities or one side of the body irrelevant talk ·        Slurred Speech ·        Difficulty to walking	·        O2 inhalation st& SOS diet NG tube feeding(if can’t able to eat diet) ·        Continuous catheterization
Pulmonary Edema	·        Breathlessness ·        Cough C or without expectoration ·        Tiredness ·        Palpitation present in severe cases	·        Bed rest with propped up position,O2 inhaltion ·        Diet: Normal
Acute pancreatitis	·        Abdomen pain especially right upper ·        Fever ·        Nausea and vomiting ·        Indigestion ·        Loss of appetite ·        Abdominal pain radiate to back	·        Diet NPO,if severe pain give supportive measures immediately
Cholelithiasis	·        Pain upper abdomen ·        Nausea,Vomiting ·        Indigestion	·        It severe pain give supportive measures
Rhinosporidiosis	·        Unilatertal nasal obstruction  Rhinoceros post nasal discharge with cough	·        Nasal packing (if epitaxis) Give supportive measures
Dengue fever	·        High fever with chills ·        Heaviness of head ·        Pain in points/Muscle ·        Extreme tiredness ·        Loss foappetities	·        Diet: More fluid intake observe ½ hearlty(TO PREVENT SHOKE)
Meningitis	·        Fever with chills ·        Headache with pain in back muscles,neck ·        Stiffness of neck ·        Nausea and vomiting ·        Loss of appetite	·        Maintain TPR chest give supportive me
Pregnancy induced hypertension	Headache,Vomiting,Blurring of vision	Admit,Maintain TPR BP control
Anteparturm Hemorrhage	Painful bleeding during pregnancy Abruptio placenta	Admit,MonitorTPR,Arrange for Blood transfusion
	Painless bleeding placenta previa	Admit,MonitorTPR,Arrange for Blood transfusion
Hyperemesiagravidorum	Continuous vomiting giddiness	Admit,Monitor TPR, Start IVF

 

 

 

 

A Solution for Improving Detection and Assisting in Faster Care Decisions

It can seem daunting to incorporate a process for collecting the information important to detecting patient deterioration—and put it to use to aid in clinical decision support. An approach to consider is making this an integral and intuitive part of the vital signs collection process that clinicians perform every day.

Welch Allyn Connex® vital signs devices can help hospitals combine vital signs measurement with the collection of additional patient observational information—all in a single workflow.

Vital signs and additional collected information are automatically calculated to generate an overall patient score—directly on the device at the bedside.

Clinicians are prompted with messages providing specific response actions based on the patient score and your facility’s protocols.

Complete information can then be sent directly to the patient’s record in the EMR.

 

Sivakumar Murugesan

Consultant Patient Safety and Quality Improvement