Effect of modified early warning system on rapid response team call outcome

Background: In-hospital cardiac arrest and death are often heralded by abnormal vital signs hours before the event. The Modified Early Warning Score (MEWS) is a physiological scoring system that assigns risk for clinical deterioration based on vital signs and clinical observation. Here we discuss our experience and effectiveness of implementation of MEWS as an important tool for triggering Rapid Response (RRT) and impact of it on patient outcome. Methods: We did a retrospective chart review of patients who had RRT called since implementation of our electronic medical record from November 2011 through June 2017 in community-based teaching hospital. The MEWS system at the time of RRT call was implemented in our hospital in 2015 and we compared the outcomes of RRT in Pre-and Post-MEWS era. Results: A total of 56,532 patients were admitted to the hospital between November 2011 and June 2017, out which 898 patients had RRTs called. There was a significant increase in RRT called from the Preto the Post MEWS Era (1.31% vs 1.97%, p = 0.03). The MEWS score in the Pre-MEWS era was significantly higher than in the Post-MEWS Era (4.39 vs 3.95 p = 0.0004). After the implementation of MEWS, the percentage of code blue was also decreasing. Conclusion: Implementation of MEWS in our institute has led to an increased number of RRT called and MEWS number at the time of RRT itself has decreased. Hence the utilization of MEWS has proven to be a useful tool in early recognition of deteriorating patients in our institution. *Correspondence to: Shahriar Dadkhah, Department of Cardiology, Presence Saint Francis Hospital, 1500 Sheridan, Unit 2J, Wilmette, IL, USA, 6009, Tel: 847-3636052; Fax: 847-864-0088; E-mail: dadkhahsc@aol.com Received: December 04, 2018; Accepted: December 12, 2018; Published: December 17, 2018 Introduction In-hospital cardiac arrest is a major public health concern with an annual incidence of 209,000 in the United States [1]. In-hospital cardiac arrest is preceded by the deterioration of a patient’s physiological parameters and vital signs [2]. Identifying and appropriately managing these vital parameters accurately and timely can be helpful in reducing inhospital cardiac events and death [3]. Therefore, the deployment of rapid response (RRT) teams at the first sign of clinical deterioration has been recommended by the Institute for Healthcare Improvement (IHI) when it launched its 100,000 Lives Campaign in 2004 [3]. Various systems for risk assessment in hospitalized patient have been developed [4]. Traditionally, an RRT is activated when a patient meets predefined clinical criteria such as an extreme change in a vital sign or a change in the level of consciousness. However, aggregate weighted systems such as Modified Early Warning Score (MEWS), Shared Early warning System (SEWS), Vitals Early Warning System (ViEWS) etc., have been found to be more accurate for detecting early cardiac arrest and need for ICU transfer [5]. An early warning system, introduced by Morgan, Williams, and Wright in 1997 as the Early Warning System (EWS) [6], and modified to a Modified EWS (MEWS) subsequently in the United Kingdom [7], is a simple systematic scoring system which uses five physiological parameters of patient’s vital signs including heart rate, respiratory rate, systolic blood pressure, temperature and consciousness level. The MEWS systems have been implemented to identify those at risk of clinical deterioration in non-ICU wards [3,8] and can predict those at risk of cardiac arrest and death within 48 hours [9-11]. MEWS systems have not only been used for recognition of early signs of clinical deterioration but also for triggering the need for more intensive care such as increased nursing attention, informing the care provider, or activating an RRT team [12]. In 2015, our community-based teaching hospital with an average of 1,0000 inpatient admissions per year, implemented a MEWS system at the time of RRT. The objective of our study was to determine the effectiveness of MEWS implementation on RRT calls and patient outcomes. Methods and materials This study is based on a retrospective chart review of all in-patients who had an RRT called since implementation of our electronic medical record from November 2011 to June 2017. The institutional review board of our institution approved this study. Inclusion criteria consisted of any adult patient admitted to the medical or surgical floor during the study period. Exclusion criteria were patients admitted directly to the intensive care unit (ICU) from Shrestha E (2018) Effect of modified early warning system on rapid response team call outcome Volume 1(1): 2-3 J Cardio Case Rep , 2018 doi: 10.15761/JCCR.1000104 the emergency department (ED) or operating room and patients younger than 18 years. All demographic data were collected from the electronic health records. The data was then divided into two periods; November 2011-January 2015 before MEWS was used (PreMEWS Era) and January 2015June 2017 after MEWS was used for RRT activation (Post-MEWS Era). For the Pre-MEWS Era, MEWS was calculated retrospectively post-hoc at the time of this study. The primary outcomes of our study were mortality and post-hospitalization disposition. Mortality data was obtained via chart review. For continuous data T-test was performed and for categorical data Binomial test was used for data analysis. P-value less than 0.05 is defined as statistically significant.