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Use the MEWS: Help Keep Our Patients Safe. Rita Borrett, RN, BSN, CMSRN Nurse Manager, 3 Surgical Elisia Heidt-Penrod, RN, BSN Nurse Manager, 4 Ortho. Introduction Dr. Jeff Crandall Medical Director of Clinical Initiatives Iowa Health System. Code Buster A3. Why We Started.

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use the mews help keep our patients safe

Use the MEWS: Help Keep Our Patients Safe

Rita Borrett, RN, BSN, CMSRN

Nurse Manager, 3 Surgical

Elisia Heidt-Penrod, RN, BSN

Nurse Manager, 4 Ortho

why we started
Why We Started

Number of Code Blues Outside of ICU

Multidisciplinary Critical Care Committee

Medical Emergency Team (MET)

Rapid Response Team

Code Blues outside of the ICU continue

Lack of vital signs within the few hours leading up to cardiopulmonary arrest

calls to the met
Calls to the MET

Calls are generally triggered:

one very abnormal vital sign

worry about the patient

Average of 22 calls/month in 2009

Average of 24 calls/month in 2010

Average of 14 calls/month in 2011

allen s met criteria
Allen’s MET Criteria
  • MET calls triggered by isolated criteria that are extremely abnormal
    • May not identify some of the more subtle signs indicating deterioration
    • May not identify deterioration at an early stage
better identification pre code
Better identification pre-code…
  • Would scoringmultiple criteria help to identify patients with subtle warning signs earlier?
  • Modified Early Warning Scoring System (MEWS)
    • Examines multiple criteria
    • Aggregate scoring of multiple criteria
what the literature says modified early warning scores mews 1 2
What the Literature SaysModified Early Warning Scores (MEWS)(1,2)


Heart Rate

Systolic B/P

Level of Consciousness


Additional assessments as score increases

Urine output

O2 Saturation

what the literature says
What the Literature Says

Value of rapid response teams

Help to decrease incidence of cardiac arrests by responding rapidly (1)

Earlier recognition results in earlier assistance

Problem: when to contact the rapid response team?

Usually contacted with significant change in vital signs or “something isn’t quite right” with the patient(1)

But, could improve response if contacted BEFORE a significant change in vital signs occurred

what the literature says13
What the Literature Says
  • Early Warning Scoring System (EWS)(4,6)
    • Designed to identify subtle vital sign changes earlier in surgical patients
    • Scores multiple criteria
  • Updated to Modified Early Warning System (MEWS)(4)
    • Further potential for identifying other (e.g., medical) patients who were at risk
    • Added O2 sat and urine output
    • Quantifies criteria into a single score that triggers intervention
  • Modified Early Warning Scoring System helps to identify signs of deterioration earlier (3)
  • Earlier recognition leads to fewer codes (3)
  • Not a great deal of research support,
    • But benefits dramatically outweigh burdens…
what the literature says15
What the Literature Says
  • MEWS helps to identify patients at risk for deterioration sooner and save lives!
    • Decreased cardiac arrests/code blue calls (1,3,4)
    • Increased MET calls (1,2,3)
    • Decreased unexpected deaths (2,4,5)
    • Decreased unplanned admission to ICU (2,5)
what the literature says16
What the Literature Says
  • MEWS empowers nurses(3) to know when to:
    • continue monitoring and routine care
    • increase monitoring of VS and when to inform others of subtle changes
    • notify the physician
    • contact the MET team
how we started
How We Started
  • A3 done by Dr. Crandall in June 2010 which proposed use of MEWS
  • Development of MEWS form for Allen Hospital
    • For the trial of the MEWS,
      • Removed notifying the physician at a score of 4
      • Added, then removed graphing of the scores
how we started22
How We Started
  • Did a chart review on one unit using the MEWS form
    • Looked at vital signs in 40-50 charts
      • 3 Medical (a general medical unit)
      • 3 Heart
    • Most patients scored < 2
      • 1 scored a 3
    • Nothing to trigger a MET call
how we started23
How We Started
  • Trial form with one nurse/two patients
    • Done on 3 Heart
    • Nurse’s opinions about potential benefit:
      • Concern for time to complete the form
      • An additional form to complete
      • Might be useful for new grads
      • Hesitant for general staff use
why continue
Why Continue?
  • Needed a better trial
    • Do it longer term on more patients
      • A better trial
      • Use is more representative of “real life”
      • Need to make an impact on a Low-Volume event (Code Blue)
        • Need to do this long term to see if it works
    • Benefits definitely outweigh Burdens
      • Nothing to lose!
continuing the trial
Continuing the Trial
  • Literature showed effectiveness of MEWS on surgical unit(5).
    • Decision to trial on 3 Surgical (general surgical unit).
continuing the trial26
Continuing the Trial
  • Oct 26, 2010—meeting with surgical unit staff to discuss trial
  • Start Oct. 27th
    • Criteria on who should be scored was established with input from staff
      • Any immediate post-op patient > age 75
      • Immediate post-op colon resection
      • Any patient transferred out of ICU
      • Recorded for 24 hrs
how it spread
How It Spread
  • 4 Ortho (general orthopedic unit)
    • Temporarily merged with 3 Surgical
    • Started December 2010
  • Ortho criteria on who should be scored was revised
    • Any patient > 65 years of age with…
      • hip fractures or joint replacements
    • Any patient with PCA with a basal
    • Any patient with epidurals
input from evidence based practice committee
Input from Evidence-Based Practice Committee
  • Nurses on both units
    • Felt it was easy to use
    • Stated it was helpful in identifying at-risk patients
    • Recommended that MEWS be spread to other units
  • Criteria for use identified
    • See next slide…
how it spread further
How It Spread Further
  • Form rolled out to other medical units on a unit by unit basis during Feb, 2011
  • Trigger to help nurses remember to use the MEWS
    • Attached to transfer out of ICU orders
    • Attached to post-surgical vitals flow sheets
    • Signs posted on all units with criteria
  • Scoring tool was made a permanent part of record
benefits of the mews
Benefits of the MEWS
  • Increased frequency of monitoring and assessments in high-risk patients
  • Can trend data on form to better identify subtle changes
  • Increases communication among healthcare providers
    • Shift-to-shift report
    • Report between disciplines
  • Increased Critical Thinking knowledge
benefits of the mews32
Benefits of the MEWS
  • Saves Lives!
    • No Code Blues on patients assessed with the MEWS so far
    • There have been several MET calls based on MEWS scores
    • Case studies
case study
Case Study
  • 49 yr old patient had incarcerated umbilical hernia with small bowel resection.
    • Immediate post-op MEWS score—1
    • 6 hrs post-op MEWS score—4
      • Urine output dropping
      • Nurse was monitoring frequently
    • 7 ½ hrs post-op MEWS score—5
      • MET call and intervention
case study34
Case Study
  • 79 yr old male post-op hemicolectomy
    • Initial post-op MEWS—4
      • Every 2 hr vitals until MEWS 1
    • 20 hrs post-op MEWS—3
      • Every 2 hr vitals and MEWS continued
    • 24 hrs post-op MEWS—5
      • MET call and physicians contacted for treatment
who should it be used for
Who should it be used for?
  • Current criteria need to be revised
    • Review of med-surg codes in 2010
      • Only 17% of patients would have met criteria for having MEWS monitored
    • Most MET calls/events happen >24 hrs after admission or surgery.
    • Primary reason for MET calls in 2010
      • Respiratory distress—41%
      • Change in level of responsiveness—28%
      • Acute change in BP/Heart Rate—20%
  • Cannot automate tool.
    • CareCast not an option at this point
    • EPIC?
      • Would require one line for MEWS score and one for level of responsiveness
    • For surgical patients, an additional piece of paper for staff
  • Staff buy-in
  • Consistent use
  • This is very preliminary data
  • Early in process of trialing this form
  • Recommendations:
    • Further education of staff and physicians
    • Incorporation into EPIC
    • Refine criteria for which patients to use the MEWS on (not an issue if it is included in EPIC)
summary final thoughts
Summary—Final Thoughts
  • Benefits outweigh Burdens
  • Worth further trialing for improved patient outcomes
  • Great promise of ease of use with EPIC
thanks for coming
Thanks for Coming!
  • Rita Borrett
  • Elisia Heidt-Penrod
  • Thanks to Teresa Gavin, RN, MS, CCRN, Clinical Nurse Specialist, Critical Care
  • Institute for Healthcare Improvement (2007). Early warning systems: Scorecards that save lives. Retrieved from
  • Mitchell, IA, McKay, H, Van Levan, C, Berry, R, McCutcheon, C, Avard, B.,…Lamberth, P (2010). A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation, 81, 658-666. doi: 10.1016/j.resuscitation.2010.03.001
  • Maupin, J & Boggs, K (2010). Hospital develops early warning system. Healthcare Risk Management, 32, 92-94.
  • Moon, A, Cosgrove, JF, Lea, D, Fairs, A, & Cressey, DM (2011). An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation, 82, 150-154. doi: 10.1016/j.resuscitation.2010.09.480
  • Maccarone, M, Guerri, I, Franchi, M, Fricelli, C, Perretta, L, Zagli, G, Spina, R, Linden, M, Bonizzoli, M, Peris, A (2010). Impact of a systematic MEWS introduction on preoperative and postoperative evaluation in urgent/emergency surgery. Critical Care, 14 (Suppl 1): P255
  • Subbe, CP, Kruger, M, Rutherford, P, & Gemmel, L (2001). Validation of a modified Early Warning Score in medical admissions. Q J Med, 94, 521-526.