Browsing Doctor of Nursing Practice (DNP) Projects by Subject "Clinical Deterioration"
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Implementation of an Early Warning System to Decrease Intensive Care Unit TransfersProblems & 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.
Implementation of the National Early Warning Score in a Military HospitalProblem & Purpose: Unrecognized clinical deterioration leads to poor outcomes including unanticipated intensive care unit (ICU) admission, cardiac arrest and death. Statistics show 59.4% of patients have one abnormal vital sign one to four hours prior to cardiac arrest. The National Early Warning Score (NEWS) assists nurses to identify early clinical decompensation and intervene to prevent poor outcomes. Previous attempts to implement NEWS and a dedicated rapid response nurse (RRN) at a community sized military treatment facility were unsuccessful for improving early recognition of clinical deterioration. Prior to implementation less than 8.3% of patients at moderate risk for clinical decompensation were assessed by the RRN. The purpose of this quality improvement project was to improve early recognition of clinical deterioration by implementing a dual approach that targets both the RRN and ward nurses. Both approaches target patients at moderate to high risk of clinical decompensation to achieve early stabilization or transfer to a higher level of care. Methods: A standardized communication tool was created and utilized by the RRNs to track and trend patients with a NEWS of three to five and as a reminder to document their assessment in the electronic health record (EHR). Re-education and a workflow diagram for ward nurses was presented during a skills fair to increase assessment and vital sign frequency according to the existing NEWS protocol. Results: Over 13 weeks, 698 NEWS triggers were analyzed. Of these NEWS greater than or equal to five triggers, 76% (n= 57) were assessed by the RRN using the communication tool. Of the 76%, 84% (n=48), were physically assessed. Increased vital sign and assessment frequency by the ward nurses was highly variable throughout the implementation phase, 6.7-80% and 0- 27.2%, respectively. Conclusions: A standardized communication tool utilized by the RRNs increased RRN adherence to the NEWS protocol, achieving early identification and assessment of patients with a NEWS of three to five. NEWS greater than or equal to five identified patients at greater risk for deterioration and were associated with increased ward nurse adherence to the NEWS protocol. Improved early identification of deterioration may decrease unanticipated intensive care unit (ICU) admissions.
Implementation of the National Early Warning Score in the Emergency DepartmentProblem & Purpose: Delayed recognition of clinical deterioration is associated with increased risk for serious adverse events, including unplanned intensive care unit (ICU) admissions. The rate of transfer of general ward patients to the ICU within 24-hours of admission from the emergency department (ED) have increased, identifying process gaps in the recognition of clinical deterioration and disposition of admitted patients from the ED. The purpose of this quality improvement project was to implement the National Early Warning Score (NEWS) in the adult ED and monitor use to promote patient admission to the appropriate level of care. Methods: The ED nursing staff were educated about NEWS prior to project implementation. NEWS values were manually calculated at the time of ED rooming and time of admission. Patients with NEWS five and greater were considered for ICU admission based on inpatient ICU acceptance policies. A 10% sample of weekly census (10 patients/day) and all admissions were obtained for data collection. Weekly chart audits were conducted over a 14-week period to monitor adherence to the new practice, observe trends, and identify potential ICU admissions for patients with NEWS five and greater. Results: Over 75% of patients received NEWS screening with appropriate documentation (n=873). Overall accuracy of NEWS calculation was 99.4%. Of the 21 patients with ED NEWS greater than five, 14 (66.7%) were admitted directly to the ICU. Of the seven patients with ED NEWS greater than five not directly admitted to the ICU, four (57%) required an unplanned ICU or interfacility transfer within 24-hours of hospitalization. Conclusion: The ED staff reported NEWS improved patient monitoring, detection of deterioration, and communication of findings to providers. Integrating NEWS into electronic health systems may promote adherence and accuracy. Higher NEWS were associated with ICU admission but admitting decisions for higher NEWS varied between admitting services. The NEWS can establish a common language across disciplines and can facilitate admitting decisions with consideration for patient acuity and resource availability. Use of NEWS five and greater in other ED settings may predict ICU admission and potentially reduce unplanned transfers.
Improving Detection of Deterioration Using the Children’s Hospital Early Warning Score ToolProblem & Purpose: The project site is a 41-bed-pediatric progressive care unit (PPCU) at an urban tertiary hospital that cares for patients with a variety of diagnoses such as congenital heart disease, respiratory illnesses, and surgical cases. Pediatric Early Warning Scores (PEWS) are used to identify at-risk patients for critical deterioration. A rapid response is a situation in which an emergency healthcare team is called to respond to a patient showing signs of medical deterioration. Lengthy intensive care unit (ICU) stays often occur after a rapid response or arrest. Currently, this unit performs PEWS with vital signs. The Children’s Hospital Early Warning Score (CHEWS) is a validated tool developed for earlier detection of deterioration in pediatric patients with complex medical problems. The purpose of this quality improvement project was to implement and evaluate the effectiveness of the CHEWS with a response algorithm on a 41-bed pediatric progressive unit to promote early recognition critical deterioration. Methods: The CHEWS was performed with vital signs using a response algorithm, which was adapted by a multidisciplinary team at the project site prior to implementation. Two components, presence of cardiac disease and patients status post abdominal surgery less than 12 months of age were scored for in addition to the tool. Bedside nurses and providers were educated using a PowerPoint video, survey, and in-person training. Ten champions received one-on-one training to reinforce education. Data was collected by manual chart auditing and evaluated using run charts. Results: Utilization of the CHEWS ranged from 29-69% with an average of 38.5% during the 14-week period. There was no change in average monthly PICU transfers or arrests. There was a decrease of average rapid response calls from pre-implementation from 8 to 5.25 monthly calls. When CHEWS was elevated, 79% of the scores had a corresponding lower PEWS score. Conclusions: These results indicate that higher compliance is necessary to assess effects of CHEWS on PICU transfers, rapid response calls, and arrests. The CHEWS scoring higher than the PEWS is consistent with the literature that demonstrated PEWS scores being lower than CHEWS scores when scored simultaneously.