14 Taylor Panek

7/30/2019 14 Taylor Panek

1/23

Cardiac Surgery Early

Warning Scoring System

Washington Hospital

Center


2/23

Cardiac Surgery Bounce Back > 48

hours Data

Identify Trends, N=13, this was for the first twoquarters of FY 2011

62% returned to SICU for Respiratory RelatedCauses

> 10% returned to the SICU for Arrythmia, Altered

Mental Status, and Hemodynamic Compromise

78% of the patients Bounced Back to the SICU onnight shift


3/23

62% of the Bounce Backs Occurred after they hadbeen on 4 NW for at least 10 days

46% where 60-69 yrs/age, and 22% where 70-89yrs/age

45% gradual decline signs of deterioration at 12

hours

Mortality rate - 30%


4/23

Goals:

Minimize the number of Failure to Rescue patients

Improve Patient Safety by early recognition and

intervention

Standardize Nursing Response to Changes inpatients status

Enhance Communication with all providers througheffective use of SBAR


5/23

Modified Early Warning Score

Tool developed in England to assist ER staff inearly identification of patients who requireadmission to the hospitals

Comprised of 4 physiological parameters and 1Observational parameter

Scores are tallied from the parameters

Score of > 2 was linked with increased likelihood ofadmission


6/23

Modified Early Warning Score

SCORE 3 2 1 0 1 2 3

SBP < 70 71-80 81-100

101-

199 130

RR < 9 9-14 15-20 21-29 > 30

Temp. < 3535-38.4

> 38.5

AVPU Alertrespond to

VoiceReacts to

PainUnres-ponsive


7/23

Validation of the Modified Early Warning Score in

Medical Admissions: QJ Med 2001; 94: 521-526

Prospective study, data collected on 709 ptsadmitted to a Medical Admissions unit

Focus of the study to assess the ability of theMEWS to identify medical patients at risk forcatastrophic deterioration.

Patients with Scores of > 4 in this study were atincreased risk for catastrophic deterioration andScores > 5 where associated with increased risk ofdeath.


8/23

Value of Modified Early Warning Score in Surgical In-

Patients: Annals of the Royal College of Surgery

England, 2006; 88:571-575

Prospective Observational Study - 334 pts

Goal - Increase earlier intervention

MEWS =>4 triggered a call out to the surgical team

Results: 57 pts/17% triggered MEWS =>4,16 pts/5% needed admission to the ICU and theremaining where managed on the ward


9/23

MEWS => 4 had a Sensitivity of 75% for admissionto the ICU and was 83% specific.

They also looked at workload on the Wards usingthis tool - average census on the Ward was 18 and

the maximum amount of pts with a MEWS of = > 4was 5 with the average being 1.


10/23

Use of the MEWS Decreased Code Blue Events: The

Joint Commision Journal on Quality and Pt.

Safety,Dec. 2009, Vol. 35 Number 12

200 Bed Community Hospital in Southwest Ohio

Goal: Decease Code Blues, Increase the call forevaluation by the RRT - Rapid Response Teamsusing a MEWS of 5 as the trigger for the call.

Provide Nursing with a tool to assist with evaluation

subtle signs that predict the likelihood ofdeterioration.


11/23

Developed an Action algorithm: MEWS=>3Increase in frequency of Vital signs with notification

of the charge nurse, Mews =>4 also includedevaluation by the clinical administrator, and MEWS=> 5 Rapid Response call.

Outcomes: Decreased Code Blues by 50% with adecrease in overall mortality over 12 months


12/23

Early Warning Systems: Scorecards that Save Lives;

Institute for Healthcare Improvement, 2011

Clear set of criteria

Uses multiple Parameters

Logical System - Nursess already do vitals and a

mental status exam routinely


13/23

J ourney to CSEWS

First step: Development of an Early WarningScoring system that would reflect the needs of theCV surgical patients


14/23

Cardiac Surgery Early Warning Score

Score 3 2 1 0 1 2 3

SBP 160

HR 130

RR 30

Resp.

Support

>6L/NC

> 50%FIO2

5-6L/NC

40-50%FIO2

1-4

L/nC RA

LOC Alert

Respond toVoice -newConfusionR

estless

Respondto Pain

Unres-ponsive


15/23

Concurrent Review with CSEWS, Cardiac Early

Warning Scoring

May-J une 2011

80 Charts over 3 non-consecutive Days

Day 1 - 30 pts - 1 pt. with a score of =>3 : tachycardia withhypotension - no bounce back to SICU

Day 2 - 30 pts - 2 pts with a score of =>3*Bradycardia and hypertension - D/C home*Respiratory Distress, Code 1 called due to changes in LOC - nobounce back


16/23

Day 3 - 20 pts, 3 pts scored => 31st pt.: respiratory distress, hypotensiontachycardia - no bounce back2nd pt.: hypotension, bradycardia, and lethargy - nobounce back3rd pt.: hypertension, tachycardia, oxygen supportat 2L/NC - no bounce back


17/23

8 week Pilot: CSEWS

CSEWS calculated every 4 hours

* Score =>3 increased frequency of vitals with

notification of the covering surgical team, resourcenurse and nursing supervisor*Score =>4 increased vitals and assessment of thepatient by the covering surgical team if no

improvement in 4 hours to consider transfer to theSICU*Score =>5 Rapid Response and immediate bedsideevaluation of the patient by the covering surgical team


18/23

Pilot CSEWSOrder set Implemented spelling out nursing orders - regardingvital signs & notification

Nursing/Tech education

SBAR Communication

Specialized charting sheets for CSEWS - they would be

turned in at the end of each shift to nursing leadership

Cards for techs highlighting abnormal vitals in red - immediatenotification to Nurse


19/23

Results, N= 224 Patients

Random Audit 80 CSEWS160 times CSEWS => 3 DURING THIS TIME PERIOD

5.16 was the Average Post op Day of Elevated CSEWS

2.38 was the average number of Days on 4 NW when elevatedCSEWS occurred

66.25% elevated CSEWS - Day shift

52.5% - scored =>3

33.75% - scored =>4

13.75% - scored =>5


20/23

reasons for elevated CSEWS:* Tachycardia - 85% had a HR 101-119* Oxygen support - 78% @ 1-4 L/nc* Hypertension - 32% had SBP 136-150* Tachypnea - 72% had RR of 21-25

68% patients received treatment for their elevatedCSEWS

1Bounce back to the SICU during pilot period, pt.did have a positive CSEWS


21/23

Cardiac Surgery Early Warning Score -

Version II

Score 3 2 1 0 1 2 3

SBP 165

HR 140

RR 30

Resp.

Support

>6L/NC

> 50%FIO2

5-6L/NC40-50%FIO2

3-4L/NCRA-

2L/NC

LOC Alert

Respond toVoice -newConfusionR

estless

Respondto Pain

Unres-ponsive


22/23

Preliminary results of Version II CSEWS

5 Bounce backs * 1V-Fib arrest - survived and was D/C

First Two Quarters of FY 2012 - No Mortality fromBounce Backs -


23/23

Where are we going from here withCSEWS

Validate the tool

?? Use for this tool in assessing readiness totransfer from the SICU to the floor

Challenges with hardwiring this into nursing practiceon the cardiac step down unit.

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