Modified Early Warning Score Effect in the ICU Patient ...

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Patient Care Services / Nursing

Modified Early Warning Score Effect in the ICUPatient PopulationAnne Rabert RN, DHA, CCRN, NE-BCLehigh Valley Health Network, [email protected]

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Published In/Presented AtRabert, A. (2013, October 29) Modified Early Warning Score Effect in the ICU Patient Population. Presented at Research Day 2015,Lehigh Valley Health Network, Allentown, PA.

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Modified Early Warning

Score Effect in the ICU

Patient Population

Anne Rabert, RN, DHA, CCRN, NE-BC

LVHN

Rapid Response Teams (RRT)

Team of credentialed health care providers

who can treat patients wherever they are

located

Emergence occurred in the late 1990s based on

the successful outcomes reported in Australia

and the United Kingdom

Composition and function of the team aligns

with the organizational capabilities

RRT at LVHN

Teams operational at the two largest acute care

campuses

Team composed of a critical care RN,

respiratory therapist, and hospitalist

Program began in 2007

Average 55-60 calls per month at the larger

campus and 20-25 calls at the smaller campus

RRT Program Goal

Primary goal of the RRT program is to reduce

the number of cardiac arrest outside of the ICU

Program at LVHN has not met this goal

Why and how could it?

Modified Early Warning Score

(MEWS)

Scoring system rating physiologic parameters at

designated intervals

Adjunctive strategy to RRT programs

Proactive approach to care rather than reactive

approach of RRT

Study its effect since no prior use in the organization

MEWS Tool Score 3 2 1 0 1 2 3

Heart Rate per

Minute Less than 40 40-50 51-100 101-110 111-129 Greater

tha

n

13

0

Systolic Blood

Pressure Less than 70 71-80 81-100 101-159 160-199 200-220 More

tha

n

22

0

Respiratory Rate per

Minute Less than 8 9-17 18-20 21-29 Greater

tha

n

30

Level of

Consciousness Unresponsive Responds to

pain Responds to

voice Alert Agitation or

confusion New onset

agitation

or

confusion

Temperature Less than

95.0° 95.1-96.8° 96.9-

100.

4°

100.5-101.3° Greater than

101.4°

MEWS Score Score 3 2 1 0 1 2 3

Heart Rate per Minute Less than 40 40-50 51-100 101-110 111-129 Greater

tha

n

130

Systolic Blood

Pressure Less than 70 71-80 81-100 101-159 160-199 200-220 More

tha

n

220

Respiratory Rate per

Minute Less than 8 9-17 18-20 21-29 Greater

tha

n

30

Level of

Consciousness Unresponsive Responds to

pain Responds to

voice Alert Agitation or

confusion New onset

agitation

or

confusion

Temperature Less than

95.0° 95.1-96.8° 96.9-

100.4

°

100.5-101.3° Greater than

101.4°

Research Study Design

Quantitative Study—Retrospective medical

record review

Case-Control Design

Cases—possess the disease or event to be studied

Controls—do not

Hypothesis tested at the 0.05 level of

significance

Research Questions

Research Question 1:

What differences exist

between case and

control group subjects

exhibiting a MEWS

score of 5 or greater at

least once in the first 24

hours of an ICU stay?

Research Question 2:

What deleterious changes

in respiratory rate occur

within eight hours prior

to a cardiac arrest

event?

Target Population

Inclusion Criteria

Patients over 18 years of age

Patients admitted to the MICU/SICU between June 1, 2011 and December 31, 2012

Cardiac arrest event (case group only)

Exclusion Criteria

Patients under the age of 18

Patients transferred to the MICU/SICU from another level one ICU on the campus

Patients admitted to the MICU/SICU with comfort care orders

Target Population Formulation

Target population included 2,792 patients

4 patients excluded because they were under 18

Case group = 45 patients experiencing a cardiac

arrest event

Control group = purposive convenience sampling

of the remaining 2,743 patients resulted in

identification of 45 subjects matched by age and

gender to those in the case group.

Data Collection

Data collection required verbatim data extraction

from 2 electronic health record systems used at the

study organization

MEWS score generation occurred after the

completion of all data collection

Small pilot sample of 10 subjects in case and control

groups occurred to verify accuracy of MEWS score

values

Continued data collection occurred with remaining group

members

Sample Demographics

Cases Controls

Length of Stay 5.6 days 3.26 days

Admission Source Emergency

Department

Emergency

Department

Admitting Service Medical ICU Medical ICU

Admitting Reason Respiratory Failure Post—operative

monitoring

RQ 1 Statistical Analysis

Conduction of McNemar’s test using bivariate

statistics

Assessed for presence of significant difference in

patients with at least one MEWS score of 5 or

greater between the case and control groups

Hypothesis testing required sample subject

categorization into two dichotomous groups of all

MEWS scores less than 5 or at least one score of 5

or greater

RQ 1 Statistical Analysis MEWS Score > 5 at least once

Group 1 = “Yes” Group 2 = “No”

Sample 49 41

Case Group 30 15

Highest Score

11 4

Average Number of times

score > 5

3 Not Applicable

Control Group 19 26

Highest Score

10 4

Average Number of times

score > 5

2 Not Applicable


McNemar’s Test Results

30 cases had at least 1 MEWS score of > 5 in

the first 24 hours of an ICU stay

13 had matching controls with at least 1 score

17 had unmatched controls

15 cases did not have any MEWS score of >5

9 had matched controls without any score > 5

6 had unmatched controls

RQ 1 Conclusions

Statistically significant results (0.035) at the 0.05

level in a unique patient population

Null hypothesis rejection; support of the alternative

hypothesis indicating a difference existed between

cases an controls with at least 1 MEWS score of > 5

Research Implications include:

Create standard communication used with cognitive

continuum theory

MEWS score of 5 or greater at least one time in the first 24

hours of an ICU stay is a cardiac arrest event predictor


Use of Wilcoxon signed-rank test to determine

difference between respiratory scores

Score 1 = immediately before cardiac arrest

Score 2 = four hours before cardiac arrest

Score 3 = eight hours before cardiac arrest

Each case subject required three Wilcoxon

signed rank tests

Score 2:1; Score 3:1; and Score 3:2


MEWS Respiratory Scores—Case Group Only (n=45)

Score 1

(Immediately before

Cardiac Arrest)

Score 2 (4 hours

before Cardiac

Arrest)

Score 3 (8 hours

before Cardiac

Arrest)

Number of Cases

with Score 45 42 38

Score Range 0-3 0-3 0-3

Mean Score 1.38 1.60 1.13

Standard Deviation 1.248 1.127 0.991

Median Score 1.0 2.0 1.0

Mode Score 0 2 0


Wilcoxon Signed-Rank Test Statistics

Score 2:Score 1 Score 3:Score 1 Score 3:Score 2

Z score -0.880 -1.314 -2.456

Significance 0.379 0.189 0.014

RQ 2 Conclusions

Null hypothesis rejection; support of the

alternative hypothesis

Contributed to the current literature in a

unique patient population

Research implications include:

Narrowing of eight hour pre-cardiac arrest

window for changes to those occurring

between four and eight hours prior to an event

Study Limitations

Single center study

Case-control design

MEWS tool

Selection and value selection

Sensitivity and specificity

Recommendations

Future Use

MEWS tool use across all inpatient units in the study organization Total Score

Respiratory parameter score

Electronic calculation

Treatment algorithms based on score values

Future Study

Non-ICU patients in the study organization

Varied MEWS score values for future study

Tool modification

Incorporation into new electronic medical record system

Adjunct treatment modality with current RRT practices

Summary

Study revealed significant outcomes of MEWS score benefit as a cardiac arrest predictor in a unique population.

Also revealed significant changes in respiratory status occurred between four and eight hours prior to a cardiac arrest event

Nursing research driving nursing practice changes

Questions

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