Implementation of an Early Warning System to Decrease Intensive Care Unit Transfers

Abstract

Problems & Purpose: Extended periods of unrecognized clinical deterioration lead to increased intensive care unit (ICU) admissions and mortality. When deteriorating patients are recognized, appropriate interventions can be implemented, which leads to a decrease in unplanned ICU admissions and improved outcomes. The ability to detect deterioration requires critical appraisal of assessment data, and evaluation of trends. Early warning systems (EWS) have been shown to help clinicians predict deterioration based upon objective physiologic parameters and assessment data. At a 187-bed hospital in Western Maryland, no standardized protocol existed to aid in the detection of early deterioration. Current practice is calling the rapid response team (RRT) based upon a single vital sign or symptom. Retrospective chart review of RRT calls, discovered patients often exhibited deterioration several hours before recognition. Methods: The purpose of the quality improvement project is to implement an EWS, specifically the national early warning system 2 (NEWS2), in a medical-surgical intermediate care area (IMC) to increase early recognition of clinical deterioration. Process measures monitored during implementation included compliance with calculating and accuracy of the calculated NEWS2 score. Outcomes included rate of ICU admissions and rate of RRT calls. Results: Throughout the twelve-week implementation phase, compliance with NEWS2 score decreased from 86% during week one of implementation, to 26% in the final week, however NEWS2 score accuracy increased from 86% in week one to 94% in the final week. Pre-implementation the rate of RRT calls for the IMC were 7.2 per 1000 IMC patient days (IPD) and 30.7 per 1000 IPD post-implementation. The rate of ICU transfers was 26.5 per 1000 IPD pre-implementation and 16.1 per 1000 IPD post-implementation. Conclusion: Overall uptake of the intervention was low, desired outcomes of increased RRT calls and decreased ICU transfers was achieved. Plans to overcome compliance include integration of the NEWS2 in the electronic medical record (EMR). NEWS2 integration into the EMR with best practice advisory may increase compliance by decreasing the workload of score calculation and providing a notification for staff that must be acknowledged. NEWS2 education for new hire orientation may increase compliance and foster a culture of patient safety.