Using the Electronic Medical

Record for Early Warning

McMaster University

Thrombosis and Atherosclerosis Research Institute

Alison Fox-Robichaud

Imagine if an in-hospital cardiac

arrest on the non ICU wards was

a never event

►Present the rationale for developing an electronic EWS

►Describe the experience and outcomes at Hamilton

Health Sciences

►Discuss some of the lessons learned from this

experience.

Objectives

► Healthcare Insurance Reciprocal of Canada (HIROC) is the major insurer of hospitals in Canada

► The HIROC Top Risks in Acute Care:

▪ #2 Failure to appreciate status changes/deteriorating

▪ #5 Healthcare acquired infections

▪ #6 Inadequate triage assessment/reassessment

► In a study from Europe RNs, residents and attending staff on a medical ward did not recognize potential deterioration (Ludikhuize et al CCM 40: 2982-6, 2012).

4

Failure to Rescue is an

important health care issue

CMPA March 2014

Multiple EWS

• The earliest published was in 1997 (EWS)• Morgan et al Clin Intensive Care

• A modified version was published and validated in 2001

(MEWS). This observational study had a OR for death of 5.4

and for ICU admission of 10.9 with a score of ≥ 5.• Subbe et al Quarterly Med J

• Variations have been developed for children (BPEWS) and

with added vitals that improve the ROC (ViEWS or NEWS),

particularly with the addition of O2 sats• Parshuram et al Crit Care, 2011

• Prytherch et al Resuscitation, 2010

• Smith et al Resuscitation, 2013

Student interested in pilot

study of an early warning

score in surgical patientsOpportunity

Introduction of an early warning score

The Hamilton Early Warning Score

3 2 1 0 1 2 3

HR/pulse<40 41 - 50 51 - 100 101 - 110 111 - 130 >130

Sys BP<70 71 - 90 91 - 170 171 - 200 >200

Resp Rate<8 8 - 13 14 - 20 21 - 30 >30

Temp<35 35.1 – 36.0 36.1- 37.9 38.0 - 39 ≥39.1

02 Sat<85 85-92 >92

02 TherapyRoom Air

≤5 l/minor

<50% by mask

>5 l/minor

50% by mask

Change in CNS from Baseline

CAM+ve

Alert Voice Pain Unresponsive

Vital signs page in Meditech

HEWS alert and action

Inception Cohort

Tam et al, Can J Gen Int Med 11, 2016

Workload vs prevention

Tam et al, Can J Gen Int Med 11, 2016

HEWS and ED sepsis recognition

Skitch et al. CJEM 2017

HEWS and ED sepsis recognition

Skitch et al. CJEM 2017

Total Cohort AUC 0.77 (0.72-0.82) Critical Event AUC 0.82 (0.75-0.90)

Supported by data from others:Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, Edelson DP. Quick Sepsis-related Organ Failure

Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in

Infected Patients outside the Intensive Care Unit. Am J Respir Crit Care Med. 2017 Apr 1;195(7):906-911.

In this cohort 47 patients meeting sepsis criteria were assigned a CTAS level of III or IV. The mean HEWS score

for these patients was 2.8 (SD=2.1), which was significantly greater than non-septic CTAS III or IV patients

(M=1.4, SD=1.7), p<0.01.

Unexpected ICU admission

15

See ePoster 40

Tam et al CCCF 2017

RRS Process and Our Focus

Pa

tie

nt C

on

ditio

n

Time

Detectable

Deterioration

RRT

Arrival

24 h

ours

(t)

Activa

tio

n

Cri

teri

a M

et

Population

• Cohort of all medical/surgical adult patients

at Hamilton General Hospital that had a new

RRT consult in response to clinical

deterioration between Jan 2016 – Sept 2016

• Mature RRS

– RRT with extensive training and

experience

– Electronic EWS

• Delayed activation defined as ≥ 1 hour

duration between activation criteria and rapid

response team arrival

733 Rapid

Response

Team Calls

576 Eligible

Rapid

Response

Team Calls

157 Excluded Rapid

Response Team

calls not related to

patient deterioration

435 First Rapid

Response

Team Calls

141 Recurrent

Rapid Response

Team Calls

Outcome No Delay

RRT

n (%)

Delay

RRT

n (%)

Unadjusted

Odds Ratio

(95% CI)

p Adjusted

Odds Ratio

(95% CI)a

p

ICU transfer 25 (22.9) 112 (34.4)1.76

(1.06, 2.90)0.027

1.96

(1.16, 3.32)0.012

Death 17 (15.6) 72 (22.1)1.53

(0.86, 2.74)0.148

1.57

(0.85, 2.90)0.147

Cardio-

pulmonary

Arrest 4 (3.7) 10 (3.1)

0.83

(0.26, 2.70)0.758

1.36

(0.36, 4.80)0.632

Composite

Outcome 35 (32.1) 158 (48.5)

1.99

(1.26, 3.14)<0.001

2.27

(1.39, 3.70)<0.001

RRT = rapid response teamaAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the

activation was related to HEWS ≥ 5 Call

Outcome No Delay

RRT

n (%)

Delay

RRT

n (%)

Unadjusted

Odds Ratio

(95% CI)

p Adjusted

Odds Ratio

(95% CI)a

p

ICU transfer 25 (22.9) 112 (34.4)1.76

(1.06, 2.90)0.027

1.96

(1.16, 3.32)0.012

Death 17 (15.6) 72 (22.1)1.53

(0.86, 2.74)0.148

1.57

(0.85, 2.90)0.147

Cardio-

pulmonary

Arrest 4 (3.7) 10 (3.1)

0.83

(0.26, 2.70)0.758

1.36

(0.36, 4.80)0.632

Composite

Outcome 35 (32.1) 158 (48.5)

1.99

(1.26, 3.14)<0.001

2.27

(1.39, 3.70)<0.001

RRT = rapid response teamaAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the

activation was related to HEWS ≥ 5 Call

Univariate and Adjusted OR

Duration of DelayLength of Rapid Response Team Activation Time

Outcome 1–4 Hr 4–8 Hr 8–12 Hr 12–24 Hr

ICU transfer,

Adjusted OR (95%

CI) a

1.39

(0.78, 2.55)

3.01

(1.43, 6.40)

2.59

(1.01, 6.51)

2.54

(1.35, 4.88)

Death,

Adjusted OR (95%

CI) a

1.20

(0.62, 2.39)

1.59

(0.64, 3.80)

1.7

(0.55, 4.89)

1.56

(0.75, 3.29)

Composite

Outcome,

Adjusted OR (95%

CI) a

1.73

(1.02, 3.00)

3.62

(1.76, 7.61)

2.49

(1.02, 6.13)

2.84

(1.55, 5.27)

aAdjusted for RRT call time, Charlson Comorbidity Index, HEWS for vital set, and if the

activation was related to HEWS ≥ 5 Call

• Smartphone App with the IBM/Thoughtwire

application with automatic calculation of the

score and integrated within Meditech.

• Three roles currently Bedside Nurse, Charge

Nurse and RACE Team. Notifications are

automatically directed to the correct role

depending on the score.

• There is no delay in reporting of patient

condition, and caregivers are aware of each

other’s status in the process.

HEWS Handheld

Lessons we are learning• All vitals signs must be mandatory

– Some allowance on temp and delirium for frequent vitals

– Aided by the electronic documentation

• Ongoing education/research is vital

– Culture change that a ward code blue can be a failure to rescue

– The impact of EMR on nursing practice needs to be evaluated

• The endpoint is not just cardiac arrest

– Composite of Cardiac arrest, unplanned ICU admission and unanticipated death

– Can facilitate EOL discussions

• The CCRT is busy…But CODE BLUE is now rare

– From 8.61/1000 admissions in FY13/14 as we started to implement

– To 4.92/1000 admissions in FY17/18

– In August we had 1 resp arrest and 1 cardiac arrest on the wards at the HGH

– All Code Blue should be audited to see if the critical event was preventable

www.hamiltonhealthsciences.cawww.hamiltonhealthsciences.ca

Thanks to all the Team (Dr. Ben Tam, Dr. Steven Skitch, Michael Xu)

Christine Probst, Director of HITS; all the members of the CCRT, students and colleagues at HHS