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Quarterman
et al.
Correspondence Abstract
Dr Antony N. Thomas Modified early warning scoring (MEWS) uses abnormalities in routine
Intensive Care Unit
observations to identify patients at risk of critical illness. Nurses recorded
Hope Hospital
Salford M6 8HD scores at or above the medical response score of 3 on a hospital clinical
UK information system during the first year of introducing MEWS to 10 wards
E-mail: Tony.Thomas@srht.nhs.uk in a university hospital. A total of 619 triggers were recorded in 365 patients.
Fifty-nine required intensive care unit (ICU)/high dependency unit (HDU)
Keywords: audit, critical illness, early
warning scoring, information systems, care; 71 died. Survival was significantly worse for initial scores > 4 (35/104
physiological deterioration, vital signs patients died) than for scores 3–4 (P < 0.004). Multivariant analysis showed
age (P < 0.001) and trigger score (P < 0.001) but not ward specialty
Accepted for publication: (P = 0.1) predicted death. Mean ages of survivors and non-survivors were
31 March 2004
64 years (SD 18) and 74 years (SD 17), respectively. Addition of a score for
age did not significantly increase the area under a receiver operator char-
acteristic curve for the predictive value of MEWS scores. The study shows
that increasing MEWS score is associated with worse outcome across a
range of specialties and that nursing staff will use a patient information
system to audit MEWS scores.
Score
3 2 1 0 1 2 3
Airway Threatened
Respiratory rate <6 6–8 9–17 18–20 21–29 >30
Systolic blood pressure (mmHg) <70 71–80 81–100 101–199 >200
Heart rate (bpm) <40 40–50 51–100 101–110 111–129 >130
AVPU score Alert Verbal stimulus Pain response Unresponsive
Temperature (∞C) <35.0 35.0–38.0 38.1–38.5 ≥38.6
Urine output (mL h-1) <10 <35
AVPU is a simple score of level of consciousness, defined as awake, responding to verbal stimulus, responding to pain and unresponsive. The lower
limit for the first point of respiratory rate was increased from 14 to 18 after the third month of the project. A trigger score of 3 was taken as the trigger
score for the nursing staff to summon medical assistance.
ing group of consultants and senior nurses from med- referencing of recorded trigger scores with other
ical, surgical and critical care disciplines as well as the information collected by the system; for example,
resuscitation officer and the critical care manager. patient demographics, length of stay, transfer
Over the next 12 months (June 2002 to May 2003) the between wards and patient outcome. Staff entering a
system was introduced into three medical, four sur- trigger score on the system carry out three steps to
gical and three orthopaedic wards. Training was pro- get to an MEWS significant event field as shown in
vided to nursing staff in teaching sessions held in the Figure 1. This field then allows them to classify an
overlap between early and late shifts. Medical staff MEWS trigger score as a number between 3 and 6 or
received induction training about MEWS and addi- more than 6. The opportunity also exists for ward
tional training in speciality teaching sessions; in addi- medical staff or ICU staff to log their attendance.
tion, opportunistic ward teaching was provided to There is a free-text field and staff can also review pre-
all staff when possible by members of the steering vious MEWS trigger score entries.
group. Nursing staff were trained to score observa- The system was used to develop monthly reports
tions using the scoring system set out in Table 1. They detailing number of trigger scores per ward and out-
were also asked to call the house staff when the come by ward as well as other information about
MEWS score was 3 or more. The failure of house ICU and high dependency admissions and times that
staff to correct the score required them to refer up to MEWS scores were entered. These reports were cir-
more senior members of staff within their team; these culated to individual wards and consultants to allow
staff could then contact the ICU registrar or consult- monthly feedback on progress. Free-text fields were
ant if required. reviewed and details of all individual patient entries
We decided to audit the introduction of MEWS were sent to the patient’s ward manager and special-
using our patient information system [Sunrise Clini- ity clinical governance lead, so they could then act on
cal Manager 3.03 (2002), iSoft Manchester, UK]. This organizational failings reviled by the entries. After
system allows staff to review results of tests and 12 months, and with ethics committee approval, it
investigations as well as standard documents and was decided to review all trigger score entries logged
patient demographics. The system is available from into the system; this review forms the basis of the
terminals on all wards. It was introduced in August results presented below. The information system was
2000 and all ward medical and most nursing staff interrogated using standard query language to iden-
used the system regularly. The decision to use this tify all MEWS entries by ward, time of entry and
patient information system was based partly on a patient demographics and outcome; free-text entries
lack of funding to provide any staff to collect audit were also retrieved. Anonimized information was
data. We also felt the system would allow cross- then exported into an Access database for subse-
134 © 2005 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 11, 2, 133–138
Patient information system and MEWS
Figure 1 Screen print to show options for recording of trigger scores or attendance by ward or intensive care unit (ICU)
medical staff. There is also a section to record free text. Three simple steps are required to obtain this screen.
quence statistical analysis using an SPSS program then investigated by grouping ages into less than
(SPSS 11.5, SPSS Inc, Chicago, IL). 50 years (0 point), 50–70 years (1 point), or over
Where a patient was admitted on more than one 70 years (2 points), producing receiver operator
occasion, these admissions were classified as separate characteristic (ROC) curves and then calculating the
patient episodes. Significant end-points were defined area under these curves with and with out age as a
as death, admission to HDU or ICU and hospital covariable, using similar method to previous pub-
discharge. lished work (Subbe et al. 2001). Significance for all
Descriptive analysis of data was performed fol- tests was set at the normal 5% level.
lowed by production of Kaplan Meier survival curves
to allow comparison of outcome by grouped trigger
Results
scores (3 or 4, or 5 or above). Outcome was defined
as death or live discharge, with the time taken from A total of 619 trigger scores were recorded in 365
first score to outcome. Multivariant analysis was admissions between 1 June 2002 and 31 May 2003.
also performed using the Cox proportional hazards In addition to this, there were only 21 entries made
model to look at the individual risk factors of trigger by ward medical staff and 41 entries made by ICU
score, age and medical speciality by ward as pooled medical staff. Twenty-four patients remained in hos-
variables to determine which factors predicted mor- pital at the end of the study period and were there-
tality. For this analysis trigger scores were treated as fore excluded from survival analysis. The mean ages
individual scores except for scores above 6, which of survivors and non-survivors were 64 years (SD
were grouped as a single score. Medical specialty was 17) and 74 years (SD 12), respectively; 63% of the
defined as medicine, general surgery or orthopaedics, patients were male. Of the 341 patients followed to
depending on the ward where the patient triggered hospital discharge, 34 patients required ICU care,
their score. Age was determined in years. The predic- 25 patients required HDU care and 71 patients
tive value of combining trigger scores with age was died.
© 2005 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 11, 2, 133–138 135
C.P.J. Quarterman et al.
Eighty-two per cent of nurse entries had additional scores and survival of patients by ward are shown in
free-text information and 68% contained the individ- Table 2 together with the number of months that the
ual physiological variables that allowed direct calcu- system was on use on each ward. Figure 3 shows the
lation of the early warning score. All scores of more relationship between trigger score and negative end-
than 6 could be ascribed using free-text entries points of death, ICU or HDU admission. Although
recorded in the clinical information system. Com- scores of 5 or above occurred in only 30% of patients,
ments that were useful for audit were made in many these patients had 47% of all negative end-points.
of the entries. Forty-three per cent of triggers scores Figure 4 shows Kaplan Meier survival plots for the
were recorded between 06:00 and 14:00, 49% cumulative survival of patients with MEWS scores
between 14:00 and 22:00, and 8% between 22:00 and of 3 or 4 compared with patients with scores of 5 or
06:00. more. Log rank tests showed a significant difference
Figure 2 shows the distribution of trigger scores for between curves with an increasingly poor prognosis
the first and highest scores recorded per patient. Sev- for higher scores (P < 0.004). Multivariant analysis
enty per cent of reported scores were 3 or 4 and 30% suggested that increasing age (P < 0.001) and increas-
were 5 or more. Further details of the number of ing MEWS score (P < 0.001) were associated with
180
160 155
140
126 Initial
120 Maximum
Frequency
100
82 78
80 76
66
60
40 32
21 17 Figure 2 Distribution of trigger scores
20 10
5 8 for the first and highest scores
1 1 0 0 0 1 1 2 recorded per patient across all wards
0
3 4 5 6 7 8 9 10 11 12 during the study period. MEWS,
MEWS score modified early warning scoring.
70
% death
60 % ICU
% HDU
50
% Frequency
40
30
20
136 © 2005 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 11, 2, 133–138
Patient information system and MEWS
Table 2 The number of scores and survival of patients by ward with the number of months that the system was on use
on each ward, and the type of wards involved in the study
% mortality of trigger
patients (n = number of
Number of MEWS triggers patients)
Time of MEWS
Type of ward use (months) 3 and 4 5 or more 3 and 4 5 or more
MEWS score age score to the MEWS score increased the area
0.8 Lower line
under the curve for the ROCs from 0.623 to 0.697, a
Score of 5, 6 or
greater difference that was not significant (P = 0.1362).
0.6
Score of 5, 6 or
greater – censored
0.4 Discussion
Upper line
Score of 3 or 4
0.2 The study clearly demonstrates that a clinical infor-
Score of 3 or 4
– censored mation system can be used to gather information
0.0 about patients triggering MEWS scores and that this
0 100 200
Time from score to death (days) information can be used to audit the introduction of
MEWS. The study unfortunately suggests that medi-
Figure 4 Kaplan Meier survival plots for the cumulative
cal staff would require specific incentives to make
survival of patients with initial MEWS scores of 3 or 4
compared with patients with scores of 5 or more. MEWS, them use the system. We are unable to tell how many
modified early warning scoring. patients triggering MEWS scores did not have their
triggers entered on to the information system; how-
ever, the number of trigger scores were similar to
those reported in other studies in surgical wards (Pit-
© 2005 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 11, 2, 133–138 137
C.P.J. Quarterman et al.
138 © 2005 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 11, 2, 133–138