Patient Safety Tip of the Week
July 15, 2014
Barriers to Success of
Early Warning Systems
We’ve done lots of
columns on early warning scores (like MEWS, PEWS, and MEOWS) as tools to help
in early recognition of patients with clinical deterioration. While the logic
behind such scoring systems seems well-founded there has been a paucity of high-level
evidence that such systems lead to substantial improvement in patient outcomes.
Because of that and other factors, hospitals in the US have been very reluctant
to adopt early warning scores into routine practice even as hospitals in the UK
have been mandated to adopt such systems.
We’ve always been
puzzled that something that seems so rational has failed to live up to its
theoretical potential. But an excellent study just published in the nursing
literature (Watson
2014) provides great insight into the barriers that impact implementation
of an early warning system.
Watson and
colleagues used a mixed methodology to evaluate factors related to their use of
PEWS (the Pediatric Early Warning Score) at a children’s hospital. The methods
included a retrospective review of VS (vital signs) and PEWS documentation,
behavioral observations of RN activities related to patient assessment, and feedback
from RN’s about workflow and their perception of PEWS.
Their chart review
found a mean delay in charting of vital signs of 20 minutes for non-RN
personnel (primarily patient care technicians) vs. 36.5 minutes for RN’s. They
also found that there was poor consistency between charted vital signs (for
heart rate and respiratory rate) and the numbers used in the PEWS. The
behavioral observation demonstrated much multitasking by RN’s, most RN’s
recorded patient assessments on paper and then used the paper when inputting
assessments into the computer, and often used VS from monitors rather than from
physical assessments. Bedside EMR charting occurred only 14% of the time.
The nurse feedback
revealed that there were significant barriers to their concurrent charting: lack
of computer availability or functionality, excess log-on times, and preferences
for not charting in front of patients/family. RN’s also explained the
discrepancy between charted VS and those used for PEWS in that they usually
wanted to use their own assessments in the PEWS rather than the assessments
done by the patient care techs. They also expressed their lack of confidence
that the PEWS could detect deterioration above and beyond their own assessment
skills.
Watson and
colleagues suggest changes to the physical environment and improved technology
interfaces to support real-time data entry as ways to improve usefulness of the
PEWS. Beside computer access or use of smartphones or tablets for documentation
would help. They also note that many EMR’s automatically populate VS into the
early warning score tool. They also suggest examination of RN and non-RN tasks,
perhaps returning VS assessment to RN’s so that data collection and
documentation would be integrated. They felt it important to acknowledge the
ambivalence RN’s had about the value of the PEWS and suggested adding RN
concerns or family concerns to the criteria for the score.
Note that the latter
(i.e. nurses felt the tool could not detect deterioration any better than they
could) has been noted before. In fact, in our March 2012 What’s New in
the Patient Safety World column “Value
of an Expanded Early Warning System Score” we noted that the expanded MEWS in a Netherlands study (Smith
2012) also used what we consider a
most valuable measure: the nurse’s bedside gestalt of the patient’s condition!
This is an
outstanding practical study which provides tremendous insight into why early
warning scores have so far failed to demonstrate clearcut
improvement in patient outcomes. It’s also a great example of how hospital-wide
or system-wide implementation of a quality improvement intervention is likely
to fail if we do not understand its impact on workflows and culture. Doing a
pilot project first with the types of assessments done by Watson and colleagues
would likely uncover many of the barriers they eventually found.
Some of our other
columns on MEWS or recognition of clinical deterioration:
- February 26, 2008 “Nightmares:
The Hospital at Night”
- April 2009 “Early
Emergency Team Calls Reduce Serious Adverse Events”
- December 15, 2009 “The
Weekend Effect”
- December 29, 2009 “Recognizing
Deteriorating Patients”
- February 22, 2011 “Rethinking
Alarms”
- March 15, 2011 “Early
Warnings for Sepsis”
- October 18, 2011 “High
Risk Surgical Patients”
- March 2012 “Value
of an Expanded Early Warning System Score”
- September 11, 2012 “In
Search of the Ideal Early Warning Score”
- May 2013 “Ireland
First to Adopt National Early Warning Score”
- September 17, 2013 “First
MEWS, Now PEWS”
- January 2014 “It
MEOWS But Doesn’t Purr”
- March 11, 2014 “We
Miss the Graphic Flowchart!”
References:
Watson A, Skipper C, Steury R, et
al. Inpatient Nursing Care and Early Warning Scores: A Workflow Mismatch. J Nurs Care Qual 2014; 29(3):
215-222
Smith T, Den Hartog D, Moerman T, et al. Accuracy of an expanded early
warning score for patients in general and trauma surgery wards. British Journal of Surgery 2012; 99: 192-197
Print “PDF
version”
http://www.patientsafetysolutions.com/