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January-February 2017 • Vol. 26/No. 1 15

William M. Parrish, DNP, RN, CCRN-K, CPHQ, is Coordinator, Nurse Residency Program, Providence Health and Services, Everett, WA. Marilyn Hravnak, PhD, RN, CRNP, FCCM, FAAN, is Professor, University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA. Linda Dudjak, PhD, RN, FACHE, is Associate Professor, University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care, Pittsburgh, PA. Jane Guttendorf, DNP, RN, CRNP, ACNP-BC, CCRN, is Assistant Professor, University of Pittsburgh, School of Nursing, Department of Acute and Tertiary Care; and Acute Care Nurse Practitioner, Department of Critical Care Medicine, UPMC Presbyterian, Surgical Intensive Care Unit, Pittsburgh, PA.

Impact of a Modified Early Warning Score on Rapid Response and

Cardiopulmonary Arrest Calls in Telemetry and Medical-Surgical Units

I n response to the Institute forHealthcare Improvement’s (2014)call for hospitals to reduce the number of cardiac arrests and sud- den life-threatening patient events, more than 1,500 hospitals across the United States have implement- ed rapid response teams (RRTs). Healthcare systems implementing these teams empower staff, and in some cases patient family members, to call a group of clinicians with advanced assessment skills quickly to the bedside to evaluate a change in patient condition. Many organi- zations implementing RRTs have demonstrated reductions in num- ber of cardiac arrests, mortality rate, and critical care unit length of stay (Maharaj, Raffaele, & Wendon, 2015).

For RRTs to be effective, organi- zational leaders must equip clini- cians with the knowledge and tools to recognize patients at risk for dete- rioration in condition. According to Chen and colleagues (2015), RRTs often are mobilized to the patient bedside when an extreme alteration occurs in one parameter of vital sign and, in many cases, after the patient is already in distress. Early warning scores (EWS) or modified early warning scores (MEWS) repre- sent a way to detect smaller changes in multiple patient parameters over time, giving clinicians an earlier indication of potential change in condition. Early recognition of an untoward change in patient condi- tion is vital to early intervention, which then can improve patient outcomes (Mapp, Davis, & Krowchuk, 2013).

Literature Review A literature search was conduct-

ed using the PubMed and Ovid databases and search terms early warning score and modified early warning score, limited to articles published 2012-2014. The search generated 361 results. Articles were selected for inclusion if they were available in full text in English, and specifically addressed impact of an EWS on RRT activations or patient outcomes (e.g., cardiac arrest, mor- tality rate).

A systematic review on the impact of EWS on patient outcomes conducted by Alam and colleagues (2014) found an evidence gap exists due to few multicenter trials using a standardized scoring system. How – ever, overall positive impact was demonstrated on clinical outcomes. Authors conducted a search of the

PubMed, EMBASE.com, and Coch – ran Library databases using the terms early warning score, hospital, hospital setting, and adults. Seven of 532 identified references were included because they were con- trolled, addres sed the im pact of EWS on patient outcomes, and included only subjects over age 16. Two of the seven studies demon- strated significant reduction in pre- implementation versus post-imple- mentation mortality rates (5.8% vs. 2.8%; p=0.046; and 1.4% vs. 1.2%; p<0.0001). Two additional studies in the systematic review also dem – onstrated positive trends in survival that did not reach statistical signifi- cance. One study reported an 8% increase in survival to discharge (p=0.47) and the other a 0.9% reduction in mortality (p=0.092).

McNeill and Bryden (2013) per- formed a systematic review evaluat-

Continuous Quality ImprovementContinuous Quality Improvement

William M. Parrish, Marilyn Hravnak, Linda Dudjak, Jane Guttendorf

To reduce the number of cardiac arrests in telemetry and medical- surgical units, a 70-bed community hospital integrated a weighted, aggregate, electronic modified early warning score into the elec- tronic medical record. Impact was evaluated via a quality improve- ment initiative.

January-February 2017 • Vol. 26/No. 116

ing the impact of RRTs on adult patient survival. Authors originally performed a search of Ovid Medline, CINAHL, Cochrane Library, Web of Science, NHS National Research Register, NHS UK Research Network Study Portfolio, and EMBASE for studies evaluating the impact of an EWS and RRTs on patient outcomes. Studies were included if they exam- ined adults and focused on one of the following outcome criteria: inci- dence of cardiac arrest, unplanned intensive care unit (ICU) admissions, ICU mortality, length of ICU stay, length of hospital stay, or inpatient hospital survival. Six of the reviewed studies also evaluated EWS. Four included aggregate weighted scoring systems with multiple patient parameters; two others used a single parameter approach. Only one of the included studies demonstrated improved hospital survival rates; however, both studies using a single parameter system demonstrated reduction in cardiac arrest rates, and two of the four using multiple parameter EWS demonstrated posi- tive impact on unexpected deaths or cardiac arrest calls. Although some of the data in the review were identi- fied as poor quality, authors conclud- ed a whole system of scoring cou- pled with clinical action is needed. In addition, aggregated early warn- ing scoring systems seemed to be more effective than single parameter triggering systems.

A retrospective observational study in an academic medical cen- ter evaluated the potential effective- ness of a MEWS based on the vital signs of medical-surgical patients collected for the 48-hour window prior to an adverse event (Ludik – huize, Smorenburg, de Rooij, & de Jonge, 2012). Authors used an aggregate weighted scoring system for vital signs. Patients were includ- ed in the study only if they experi- enced emergency surgery, unplan – ned admission to the ICU, car- diopulmonary resuscitation, or unexpected death. Of 204 patients meeting these inclusion criteria, 81% (n=166) experiencing an adverse event achieved an EWS of 3 or more at least once during the 48 hours preceding the event.

Ludikhuize and colleagues (2014) also conducted a quasi-experimen- tal study to evaluate the degree to which a MEWS used three times daily, versus an EWS obtained only when prompted by a clinical event, impacted RRT activation at an aca- demic medical center. Data were collected for 3 consecutive months on adult patients to include vital signs and adverse events, such as unplanned admission to the ICU or cardiopulmonary arrest. These data were analyzed for 372 patients who were monitored using an EWS pro- tocol and 432 control patients. Authors concluded scoring occur – red more often when used by proto- col (70%, n=2,513) than when trig- gered by a clinical event (2%, n=65). Addi tionally, the rate of RRT calls per admission on the units using protocols were double those of units not using protocols.

Huh and co-authors (2014) pub- lished a retrospective cohort study of RRT activation through the use of an electronic aggregate weighted EWS, compared to a clinician- or provider-activated call prompted by established RRT activation criteria. Scores were calculated based on scoring criteria built into the elec- tronic medical record. Authors col- lected data on all inpatient and out- patient RRT activations in an aca- demic medical center for 24 consec- utive months (n=3,030), including outcome information, such as trans- fer to a higher level of care or death during resuscitation. RRT activa- tions prompted by the electronic medical record EWS calculation resulted in fewer ICU transfers (192 vs. 400; p=0.0000) and deaths dur- ing cardiopulmonary resuscitation (2 vs. 8; p=0.0000) than RRT activa- tions by a clinician or provider.

Improvement Needs In an attempt to decrease the

number of cardiopulmonary arrests occurring outside the ICU, the pri- mary author’s medical center formed a group of nurse educators, leaders, and nursing informatics staff to establish a MEWS that would provide clinical staff with an early alert to changes in patient

condition. Before facility imple- mentation of an electronic MEWS, cardiopulmonary arrest and RRT calls were initiated by a care provider when a patient was found to be in distress or when a signifi- cant alteration in vital signs was noted. For example, an RRT call may have been initiated when a patient care technician reported to the primary nurse a patient was severely short of breath during rou- tine vital signs. While suggested activation criteria were provided to clinicians during introduction of the facility RRT in 2006, no formal warning system existed to prompt staff of a potential change in patient condition.

With the implementation of the electronic MEWS on the medical- surgical and telemetry units at the institution, a quality improvement initiative was launched to provide a framework for evaluating the impact of the electronic MEWS. Three evaluation metrics were iden- tified: the number of RRT calls, the number of cardiopulmonary arrests occurring on the noncritical care units, and survival to discharge fol- lowing an RRT call or a cardiopul- monary arrest. Implementation groups before and after MEWS implementation were compared.

This project was conducted in a 70-bed suburban acute care facility, which included a 36-bed medical- surgical unit, a 26-bed telemetry unit, and an 8-bed ICU. The MEWS was implemented on the medical- surgical and…