Managing the

Deteriorating
Patient

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 Objectives

 Clarify requirement for managing

deteriorating patient condition according to 5th
Edition Standard - COP.3.1

 Describe monitors use to evaluate impact of

the Rapid Response Team Program

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 5th Edition - NEW Standard COP.3.1

Recognizing patients deteriorating condition

• Staff are trained to recognize and respond to
change in a patient’s condition
• Development of systematic approach for
response
• Development & implementation of criteria
describing early warning signs of patient
deterioration
• Based on criteria, staff seek early assistance

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• Patient and family informed on how to seek
assistance when they are concerned
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 Rapid Response Teams- Purpose
 To increase early intervention and stabilization to
prevent clinical deterioration of any individual prior to
cardiopulmonary arrest or other life-threatening event

 To decrease the number of cardiopulmonary arrests

that occur outside of the intensive care unit and
emergency department

 To increase patient, family and staff satisfaction

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 To decrease hospital mortality

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 Problem: Missed warning signs

 Many times, hospitalized patients exhibit early

warning signs in the hours before experiencing
cardiopulmonary arrest,
– signs are often not recognized
– "failure to rescue“ 3rd most frequent sentinel
event reported
 As many as 80 percent of hospitalized patients
have physiological parameters outside normal

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ranges in the 24 hours before ICU admission

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 Failure To Rescue - AHRQ Definition
 Failure to rescue (i.e., prevent a clinically important
deterioration, such as death or permanent disability)

 from a complication of an underlying illness (e.g.,

cardiac arrest in a patient with acute myocardial
infarction)

 or a complication of medical care (e.g., major

hemorrhage after thrombolysis for acute

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myocardial infarction).

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 Early Warning signs - MEWS
“The MEWS (Modified Early Warning Scoring)
 allows the nurses to start making
uncomfortable decisions
 have the support to back them up”

System only as good as implemented and

supported.
• Human error can be the downfall

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• Poor compliance could cause failure

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 Consider 6 elements for reducing
harm from deterioration
1. Physiological observations recorded on all
patients
2. Recorded by staff trained to understand their
clinical relevance and act upon them
3. Physiological track and trigger systems should
be used
4. You should have a graded response strategy
5. An escalation protocol should be in place
6. A good communication tool should be utilized

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 Early Warning Signs - MEWS
Vital Sign Score 0 Score 1 Score 2 Score 3
Heart rate: 50 to 100 beats 41 to 50 or 101 40 or fewer or 130 or greater)
per minute to 110 111 to 129
Systolic blood 101 to 199 mm 81 to 100 71 to 80 or 200 70 or lower
pressure Hg or greater
Respiratory 9 to 14 breaths 15 to 20 8 or fewer or 21 30 or more
rate per minute to 29
Temperature 95 to 101.2 less than 95 or
degrees F 101.3 or higher
Level of alert responds to responds to unresponsive
consciousness voice pain

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Take vital signs once every 12 hours, aggregates
numbers for total. This is the MEWS score.
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 Actions Taken to Prevent Deterioration
 Total score of 0 to 2: Continue routine/ordered monitoring
of vital signs.
 Score of 3: Increases vital sign monitoring frequency to 2-
hour intervals & calculate the MEWS score each time. If the
patient remains at "3" for three consecutive readings, the nurse
calls the clinical administrator to assess the patient
 Score of 4: Inform patient's physician, charge nurse, and
clinical administrator of elevated score. The clinical
administrator assesses the patient. The nurse increases vital
sign monitoring frequency to 2-hour intervals & calculates the
MEWS score each time. Nurse also measures fluid input and

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output & notifies clinical administrator if urine output falls below
100 cc every 4 hours.
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 Actions Taken to Prevent Deterioration
• Score of 5: Nurse calls rapid response team (RRT) and
informs patient's physician of the score. Nurse increases the
frequency of vital sign monitoring, including pulse oximetry, to
hourly. If the patient remains at "5" for three consecutive
readings, the nurse requests a physician's order for possible
trans
 Score of 6 or greater: Nurse calls RRT and patient's
physician immediately. Typically, patients with a score of "6" or
greater are immediately transferred to a higher level of care.
Often higher level of care (typically the ICU).

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Major Outcomes Considered
 Hospital mortality rates
 Cardiopulmonary arrest or codes
 Hospital length of stay

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 Monitoring Measures

• Number of calls to RRT (Rapid

Response Team)

• Number of unplanned transfers to

higher level of care

• Number of cardiopulmonary arrests

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 Questions
Comments

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