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Modified Early Warning System (MEWS): Reducing Mortality Through Early Intervention
Teresa Anderson, RN, MSN, PhD, NE-BCVice President Office of Quality,Vidant Medical Center
Hazel D. Pennington, RN, MSNManager, Corporate QualityVidant Health
• Identify problem
• Identify goal
• Develop multidisciplinary team
• Determine metrics
• Implement PDSA cycle
• Develop system implementation plan
• Future state
3
Objectives
• In FY 2015 at Vidant Health, twenty percent (20%) of serious safety events were the result of a failure to recognize signs of clinical deterioration which caused a delay in treatment of care.
4
Problem
5
Time to Take a Poll
Improve patient outcomes by 10% through earlier implementation of interventions during the stage of vulnerability instead of at the catastrophic stage.
6
Intended Goal
Kodali, S. "Situational Awareness and Emergent Response Systems in the Context of Stages of Clinical Deterioration in the Hospital." J Nurs Care 3.171 (2014): 2167-1168.
The earlier we intervene the higher the chances of rescuing patients
• Form MEWS Multidisciplinary Committee
• Choose an Early Warning System
• Perform Density Analysis
• Determine Metrics
• Identify Pilot Units
7
Planning
MEWS Score Actions
0-2 • Continue routine/ordered monitoring and AVPU* assessment
3 • Increase VS frequency and AVPU assessment to every 1 hour x 3, confirm MEWS score each time
• If a patient remains at a MEWS score of 3 for 3 consecutive sets of Vital Signs, the nurse should resume
routine vital signs. If there is an escalation in the MEWS score, the MEWS protocol should restart.
4 • Actions for MEWS 3
• Apply pulse oximeter
• Apply cardiac monitor
• Inform provider and develop plan of care
➢ 5 • Increase VS frequency and AVPU assessment to every 30 minutes x 4, confirm MEWS score each time
• Actions for MEWS 4
• Notify ERT and/or Nursing Supervisor
Fluctuating MEWS
Score • Implement protocol each time BPA is triggered.
8
MEWS Protocol
• Pilot Metrics
• BPA Frequency
• Escalation of Care
• Final Metrics
• Codes Outside ICU
• ERT Activations
• Mortality
9
Determining Metrics
PLAN
Bi-monthly Committee Meetings
Determine EWS
Gap Analysis
Education Strategies
EHR Reports
Alert Fatigue
DO
Pilot Gen Med Unit at AMC and Regional
Hospital
Daily Feedback
Rounding
STUDY
BPA Frequency
Interventions
MEWS Parameters
Escalation of Care
Work Burden
Workflow
ACT
MEWS Parameters Refinement
Workflow Modifications
Intervention Adjustments
10
PDSA Cycle
• Pilot
• Regional Spread
• Daily Feedback
• Academic Medical Center Spread
• Real time Coaching
11
Implementation Strategy
12
Vidant HealthCurrent Outcomes
0
5
10
15
20
25
0
100
200
300
400
500
600
700
800
900
1000O
ct-1
5
No
v-15
De
c-1
5
Jan
-16
Feb
-16
Ma
r-1
6
Ap
r-16
May
-16
Jun
-16
Jul-
16
Au
g-16
Sep
-16
Oct
-16
No
v-16
Dec
-16
Jan
-17
Feb
-17
Mar
-17
Ap
r-17
Ma
y-1
7
Jun
-17
Jul-
17
Au
g-17
Sep
-17
Oct
-17
No
v-17
De
c-1
7
#To
tal C
od
es O
uts
ide
ICU
#To
tal E
RT
Act
ivia
tio
ns
VH Total ERT Activations VH Codes Outside ICU
13
Vidant Community HospitalsCurrent Outcomes
0
2
4
6
8
10
12
14
0
2
4
6
8
10
12
14
16
18
Oct
-15
No
v-1
5
Dec
-15
Jan-
16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
Dec
-16
Jan-
17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun
-17
Jul-
17
Au
g-1
7
Sep
-17
Oct
-17
No
v-1
7
Dec
-17
#To
tal C
od
es O
uts
ide
ICU
#To
tal E
RT
Act
iva
tio
ns
VCOM Total ERT Activations VCOM Codes Outside ICU
14
Vidant Medical CenterCurrent Outcomes
0
2
4
6
8
10
12
14
0
100
200
300
400
500
600
700
800
900
1000O
ct-1
5
No
v-1
5
Dec
-15
Jan-
16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun-
16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
Dec
-16
Jan-
17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun-
17
Jul-
17
Au
g-1
7
Sep
-17
Oct
-17
No
v-1
7
Dec
-17
#To
tal C
od
es
Ou
tsid
e IC
U
#To
tal E
RT
Act
ivat
ion
s
VMC Total ERT Activations VMC Codes Outside ICU
15
Vidant Community HospitalsMortality Index
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Oct
-15
No
v-1
5
Dec
-15
Jan-
16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
Dec
-16
Jan-
17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun
-17
Jul-
17
Au
g-1
7
Sep
-17
Mo
rtal
ity
Ind
ex
VCOM Mortality Index VCOM FY 2017 Improvement Target Linear (VCOM Mortality Index)
16
Vidant Medical CenterMortality Index
0
0.2
0.4
0.6
0.8
1
1.2
Oct
-15
No
v-1
5
Dec
-15
Jan-
16
Feb
-16
Mar
-16
Ap
r-1
6
May
-16
Jun-
16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
Dec
-16
Jan-
17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun-
17
Jul-
17
Au
g-1
7
Sep
-17
Mo
rta
lity
Ind
ex
VMC Mortality Index VMC FY 2017 Improvement Target Linear (VMC Mortality Index)
• Set specific expectations
• Implement multiple education strategies
• Message EHR as communication tool
• Define communication channels
17
Lessons Learned
• Combine inpatient Systemic Immune Response Syndrome (SIRS) Best Practice Advisory (BPA) and MEWS BPA
• Discontinue 36˚ post-operative snooze
• Include in Adult Admission Order Sets
• Timely Vital Sign Documentation Report
18
Future State
19
Questions?
Modified Early Warning System (MEWS): Reducing Mortality Through Early Intervention
Teresa Anderson, RN, MSN, PhD, NE-BC
Vice President Office of Quality,
Vidant Medical Center
252/847-4100
Hazel D. Pennington, RN, MSN
Manager, Corporate Quality
Vidant Health
252/847-6330
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