Use the MEWS:
Help Keep Our Patients Safe
Rita Borrett, RN, BSN, CMSRN
Nurse Manager, 3 Surgical
Elisia Heidt-Penrod, RN, BSN
Nurse Manager, 4 Ortho
Introduction
Dr. Jeff Crandall
Medical Director of Clinical
Initiatives
Iowa Health System
Code Buster A3
Why We Started
Number of Code Blues Outside of
ICU
Multidisciplinary Critical Care Committee
Medical Emergency Team (MET)
Rapid Response Team
Code Blues outside of the ICU
continue
Lack of vital signs within the few hours
leading up to cardiopulmonary arrest
Number of MET calls/1000
discharges vs. Number of Code
Blues/1000 discharges
35
30
25
20
MET calls
Code Blue
15
10
5
0
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Number of MET calls vs. Number of
Code Blues outside of ICU/Cath lab
35
30
25
20
MET calls
Code Blue
15
10
5
0
April
June
August
Calls to the MET
Calls are generally triggered:
one very abnormal vital sign
worry about the patient
Average of 22 calls/month in 2009
Average of 24 calls/month in 2010
Average of 14 calls/month in 2011
Allen’s Criteria for Calling MET
Allen’s MET Criteria
MET calls triggered by isolated
criteria that are extremely abnormal
May not identify some of the more subtle
signs indicating deterioration
May not identify deterioration at an early
stage
Better identification pre-code…
Would scoring multiple criteria help to
identify patients with subtle warning
signs earlier?
Modified Early Warning Scoring
System (MEWS)
Examines multiple criteria
Aggregate scoring of multiple criteria
What the Literature Says
Modified Early Warning Scores (MEWS)(1,2)
Respirations
Heart Rate
Systolic B/P
Level of Consciousness
Temperature
Additional assessments as score increases
Urine output
O2 Saturation
What the Literature Says
Value of rapid response teams
Help to decrease incidence of cardiac arrests by
responding rapidly (1)
Earlier recognition results in earlier assistance
Problem: when to contact the rapid response
team?
Usually contacted with significant change in vital
signs or “something isn’t quite right” with the
patient(1)
But, could improve response if contacted BEFORE
a significant change in vital signs occurred
What the Literature Says
Early Warning Scoring System (EWS)(4,6)
Designed to identify subtle vital sign changes
earlier in surgical patients
Scores multiple criteria
Updated to Modified Early Warning System
(MEWS)(4)
Further potential for identifying other (e.g.,
medical) patients who were at risk
Added O2 sat and urine output
Quantifies criteria into a single score that
triggers intervention
MEWS
Modified Early Warning Scoring
System helps to identify signs of
deterioration earlier (3)
Earlier recognition leads to fewer
codes (3)
Not a great deal of research support,
But benefits dramatically outweigh
burdens…
What the Literature Says
MEWS helps to identify patients at
risk for deterioration sooner and save
lives!
Decreased cardiac arrests/code blue
calls (1,3,4)
Increased MET calls (1,2,3)
Decreased unexpected deaths (2,4,5)
Decreased unplanned admission to ICU
(2,5)
What the Literature Says
MEWS empowers nurses(3) to know
when to:
continue monitoring and routine care
increase monitoring of VS and when to
inform others of subtle changes
notify the physician
contact the MET team
How We Started
A3 done by Dr. Crandall in June 2010
which proposed use of MEWS
Development of MEWS form for Allen
Hospital
For the trial of the MEWS,
Removed notifying the physician at a
score of 4
Added, then removed graphing of the
scores
MEWS Form
MEWS Scoring
MEWS Scoring
MEWS Scoring
How We Started
Did a chart review on one unit using the
MEWS form
Looked at vital signs in 40-50 charts
3 Medical (a general medical unit)
3 Heart
Most patients scored < 2
1 scored a 3
Nothing to trigger a MET call
How We Started
Trial form with one nurse/two patients
Done on 3 Heart
Nurse’s opinions about potential benefit:
Concern for time to complete the form
An additional form to complete
Might be useful for new grads
Hesitant for general staff use
Why Continue?
Needed a better trial
Do it longer term on more patients
A better trial
Use is more representative of “real life”
Need to make an impact on a Low-Volume
event (Code Blue)
– Need to do this long term to see if it works
Benefits definitely outweigh Burdens
Nothing to lose!
Continuing the Trial
Literature showed effectiveness of
MEWS on surgical unit(5).
Decision to trial on 3 Surgical (general
surgical unit).
Continuing the Trial
Oct 26, 2010—meeting with surgical
unit staff to discuss trial
Start Oct. 27th
Criteria on who should be scored was
established with input from staff
Any immediate post-op patient > age 75
Immediate post-op colon resection
Any patient transferred out of ICU
Recorded for 24 hrs
How It Spread
4 Ortho (general orthopedic unit)
Temporarily merged with 3 Surgical
Started December 2010
Ortho criteria on who should be
scored was revised
Any patient > 65 years of age with…
hip fractures or joint replacements
Any patient with PCA with a basal
Any patient with epidurals
Input from Evidence-Based Practice
Committee
Nurses on both units
Felt it was easy to use
Stated it was helpful in identifying at-risk
patients
Recommended that MEWS be spread to
other units
Criteria for use identified
See next slide…
Criteria for Use of MEWS
How It Spread Further
Form rolled out to other medical units on a
unit by unit basis during Feb, 2011
Trigger to help nurses remember to use the
MEWS
Attached to transfer out of ICU orders
Attached to post-surgical vitals flow sheets
Signs posted on all units with criteria
Scoring tool was made a permanent part of
record
Benefits of the MEWS
Increased frequency of monitoring
and assessments in high-risk patients
Can trend data on form to better
identify subtle changes
Increases communication among
healthcare providers
Shift-to-shift report
Report between disciplines
Increased Critical Thinking knowledge
Benefits of the MEWS
Saves Lives!
No Code Blues on patients assessed
with the MEWS so far
There have been several MET calls
based on MEWS scores
Case studies
Case Study
49 yr old patient had incarcerated
umbilical hernia with small bowel
resection.
Immediate post-op MEWS score—1
6 hrs post-op MEWS score—4
Urine output dropping
Nurse was monitoring frequently
7 ½ hrs post-op MEWS score—5
MET call and intervention
Case Study
79 yr old male post-op hemicolectomy
Initial post-op MEWS—4
Every 2 hr vitals until MEWS 1
20 hrs post-op MEWS—3
Every 2 hr vitals and MEWS continued
24 hrs post-op MEWS—5
MET call and physicians contacted for
treatment
Who should it be used for?
Current criteria need to be revised
Review of med-surg codes in 2010
Only 17% of patients would have met criteria
for having MEWS monitored
Most MET calls/events happen >24 hrs
after admission or surgery.
Primary reason for MET calls in 2010
Respiratory distress—41%
Change in level of responsiveness—28%
Acute change in BP/Heart Rate—20%
Barriers
Cannot automate tool.
CareCast not an option at this point
EPIC?
Would require one line for MEWS score and
one for level of responsiveness
For surgical patients, an additional piece
of paper for staff
Staff buy-in
Consistent use
Number of MET calls/1000
discharges vs. Number of Code
Blues/1000 discharges
35
30
25
20
MET calls
Code Blues
15
10
5
0
Oct-10 Nov-10 Dec-10 Jan-11 Feb-11
Number of MET calls vs. Number of
Code Blues outside of ICU/Cath lab
35
30
25
20
MET Calls
Code Blues
15
10
5
0
Oct-10 Nov-10 Dec-10 Jan-11 Feb-11
MET Calls/1000 pt days—Surgical vs.
Medical Units
25
20
15
Surgical Units
Medical Units
10
5
0
3rd Q
Oct
Nov
Dec
Jan
Feb
Summary
This is very preliminary data
Early in process of trialing this form
Recommendations:
Further education of staff and physicians
Incorporation into EPIC
Refine criteria for which patients to use
the MEWS on (not an issue if it is
included in EPIC)
Summary—Final Thoughts
Benefits outweigh Burdens
Worth further trialing for improved
patient outcomes
Great promise of ease of use with
EPIC
Questions?
Thanks for Coming!
Rita Borrett
BorretRA@ihs.org
Elisia Heidt-Penrod
HeidtEL@ihs.org
Thanks to Teresa Gavin, RN, MS,
CCRN, Clinical Nurse Specialist,
Critical Care
References
1.
Institute for Healthcare Improvement (2007).
Early warning systems: Scorecards that
save lives. Retrieved from http://www.ihi.org
2.
Mitchell, IA, McKay, H, Van Levan, C, Berry,
R, McCutcheon, C, Avard, B.,…Lamberth, P
(2010). A prospective controlled trial of the
effect of a multi-faceted intervention on early
recognition and intervention in deteriorating
hospital patients. Resuscitation, 81, 658666. doi:
10.1016/j.resuscitation.2010.03.001
References
3.
Maupin, J & Boggs, K (2010). Hospital
develops early warning system. Healthcare
Risk Management, 32, 92-94.
4.
Moon, A, Cosgrove, JF, Lea, D, Fairs, A, &
Cressey, DM (2011). An eight year audit
before and after the introduction of modified
early warning score (MEWS) charts, of
patients admitted to a tertiary referral
intensive care unit after CPR. Resuscitation,
82, 150-154. doi:
10.1016/j.resuscitation.2010.09.480
References
5.
6.
Maccarone, M, Guerri, I, Franchi, M, Fricelli, C,
Perretta, L, Zagli, G, Spina, R, Linden, M,
Bonizzoli, M, Peris, A (2010). Impact of a
systematic MEWS introduction on preoperative
and postoperative evaluation in
urgent/emergency surgery. Critical Care, 14
(Suppl 1): P255
Subbe, CP, Kruger, M, Rutherford, P, &
Gemmel, L (2001). Validation of a modified
Early Warning Score in medical admissions. Q J
Med, 94, 521-526.