Modified Early Warning System
Version 6-22-2017
Introduction
• Cardiac arrests in hospitals are usually preceded by observable signs of deterioration, often six to eight hours before the arrest occurs.
• Early recognition of these signs and prompt treatment can reduce death rates in hospitalized patients.
• The Modified Early Warning System (MEWS) has been proposed as a simple, automated bedside scoring system to identify patients at risk for subsequent deterioration.
• NMH will be incorporating MEWS into our workflow to aid in recognition of customer deterioration.
Objectives
• At the conclusion of this module, individuals will be able to:
- Define the purpose of Modified Early Warning System (MEWS) in the inpatient setting
- Identify the components that contribute to the MEWS score
- Understand MEWS scoring and MEWs levels at NMH
- Explain MEWS Intervention Expectations
- Describe documentation expectations as they relate to MEWS
- Associate available tools in EPIC to view and
monitor MEWS scoring and trends
Who does this apply to?
Included: All Medical-Surgical Units, East 2, Inpatient Rehab, OB (non-laboring customers) and MGH-ICC
Excluded: OR, PACU, ED, ICU, LDR, patient with a comfort care order.
Please Note: All areas are receiving the module for
awareness and expectations when floating or receiving a
customer from one of the inclusive areas.
MEWS Definitions
Components of MEWs
• The MEWS takes into account several physiological parameters:
- Heart Rate (HR)
- Mean Arterial Pressure (MAP) - Respiratory Rate (RR)
- Temperature (Temp)
- Oxygen Delivery Mode (O2) - Glucose
- Level of Consciousness (LOC)
- White Blood Cell (WBC) - (within 24hrs) - Bands - (within 24hrs)
- Lactate - (within 24hrs, most recent)
Overview of Scoring
• Each parameter is given a specific score based on the value and it’s deviation from the defined MEWs range.
• The values are auto-calculated based off the last documented value.
• The score accounts for labs resulting in the last 24 hours (or less).
• Total score is based on most recent values.
Example: Heart rate is 42, giving a score of 1 because it
is lower than the “normal” range.
MEWS Scoring System
Heart Rate
• HR pulls from vital signs navigator or flow sheet.
• HR: 51-100 beats per minute (bpm) is considered standard for MEWS
• If outside of the standard, greater than 100 bpm or less
than 51 bpm will trigger a point.
Mean Arterial Pressure
• Mean arterial pressure (MAP) is the average arterial pressure during a cardiac cycle.
Because systole accounts for one-third of the cardiac cycle and diastole accounts for two-thirds of the cardiac cycle, the formula for determining MAP is as follows:
• MAP = [(systolic pressure) + (2 x diastolic pressure)] ÷ 3
• MAP is highest in the aorta and decreases at more peripheral locations in the circulatory system
• MAP is a better indicator of blood pressure than looking at just systolic or diastolic pressure.
• MAP is auto calculated behind the scenes using the standard blood pressure numbers.
• Conditions that may cause:
• Low MAP (64 or less): Hypovolemic shock, sepsis, stroke, hemorrhage
• High MAP (Greater than 114): concern the body is stressed and working too hard
Respiratory Rate
• RR pulls from vital signs navigator or flow sheet.
• RR: 9-20 breaths per minute is considered standard for MEWS
• If outside of the standard, greater than 20 breaths per minute or less than 9 breaths per minute will trigger two points.
(-) Points (+)
Criteria 3 2 1 0 1 2 3
RR ≤8 9-20 21-29 ≥30
Temperature
• Temperature pulls from vital signs navigator or flow sheet.
• Temperature: 36.1-38 degrees Celsius is considered standard for MEWS
• If outside of the standard, there is a point assigned based on how far outside of the standard the temperature is. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
Temp <35.0 35.1-36 36.1-38 38.1-38.5 >38.6
Oxygen
• Oxygen pulls from the O2 Delivery Source row in the vital signs navigator or flow sheet.
• Oxygen device: Room air and Nasal cannula with up to 3Ls of Oxygen is considered standard for MEWS
• If outside of the standard, there is a point assigned based on how oxygen needs increase beyond the standard. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
O2 Any Other O2
Device
≥5L Nasal Cannula
≤4L Nasal Cannula
Room Air
Glucose
• Glucose pulls from the most recently documented glucose if done within 24 hours. It will pull the most recent result from any of the following:
- Lab POCT Value (Not from the Manual Entry Blood Glucose on flowsheet)
• Glucose: A value of 70-150 is considered standard for MEWS
• If outside of the standard, there is a point assigned based on how far the glucose level varies beyond the standard. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
Glucose (most recent within 24 hrs – includes lab, POCT, finger stick)
<55 55 -69 70-150 150-250 >250
Level Of Consciousness
• LOC pulls from the flowsheet row found in the Neurological section of the System Assessment.
• LOC: If documented as WDL or Awake/Alert is considered standard for MEWS
• If outside of the standard, there is a point assigned based on how far LOC is beyond the standard. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
LOC
Comatose, unresponsive,
somnolent, obtunded
Lethargic,
stuporous Drowsy Alert, Awake
White Blood Cell Count
• WBC pulls from the most recent (Up to 24 hours) WBC count in the lab results section.
• WBCs: A value of 4-12 is considered standard for MEWS
• If greater than 12 or less than 4, two points will be assigned to the MEWS score. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
WBC
(most recent within 24hrs) <4 >12
Bands
(-) Points (+)
Criteria 3 2 1 0 1 2 3
Bands
(most recent within 24hrs)
> 10%
• Bands pulls from the most recent (Up to 24 hours) lab results in the lab section.
• Bands: A value of 10% or less is considered standard for MEWS
• If greater than 10%, three points will be assigned to the
MEWS score. (as noted above)
Lactic Acid
• Lactic Acid pulls from the most recent (Up to 24 hours) lab results in the lab section.
• Bands: A value of 2 or less is considered standard for MEWS
• If greater than 2, a point will be added based on the how far beyond standard the level is. (as noted above)
(-) Points (+)
Criteria 3 2 1 0 1 2 3
Lactate
(most recent within 24hrs – includes lab, POCT)
≤2 2.1-2.9 3-4 >4
Putting It Together
MEWS Levels
To mimic current threat level verbiage out there, our MEWS levels will be designated by color and concern level:
• Green = Low
• Blue = Guarded
• Orange = High
• Red = Severe
MEWS Levels
• Customers who are decompensating will have a higher score.
• As their numbers increase, their “MEWS LEVEL” will change.
• MEWS Levels are:
• Score 0-2/Green = Low
• Score 3-4/Blue = Guarded
• Score 9-10/Orange = High
• Score 11+/Red = Severe
Overview
When hovering over score it indicates which components are out of the desired range, creating the score.
MEWS Score will be visible on customer list.
MEWS Documentation
• Every 8 hours the MEWS Score will need to be addressed.
• Actions completed within the Vital Signs Flowsheet.
• RN is responsible for placing an appropriate selection in the
“MEWS Interventions Performed” row
MEWS Documentation
(continued)• If the customer begins to decline, the score will change if the appropriate parameters are affected.
• The RN will be asked to address the change in score
as noted in the row details:
Flowsheet Overview
NOTE:
✓Scores do not replace RN assessments and critical thinking.
Actions are best practice for most customers, however
each customer needs to be assessed for appropriate
level of intervention.
MEWS Level: Low
• Score 0-2
• Green = Low
• Action:
- None
• Document:
- Reviewed, No action Taken
MEWS Level: Guarded
• Score 3-4
• Blue = Guarded
• Action:
- Increase frequency of RN assessments/vitals and review interventions as appropriate
• Document:
- Increase frequency of RN assessments/vitals
MEWS Level: Guarded
• Score 5-8
• Action:
- Increase frequency of RN assessments/vitals and review interventions as appropriate
- Notify Charge RN of status
• Document:
- Increase frequency of RN assessments/vitals
- Notify Charge RN of status
MEWS Level: Guarded
• Score 9-10
• Orange = High
• Action:
- Assess the Patient
- Notify treating provider
- Provider to complete a comprehensive
assessment of patient within 60 minutes; if provider unable to get to patient within 60
minutes then activate the Rapid Response Team
• Document:
- Patient assessed - Notified Provider
- Rapid response activated (if appropriate)
MEWS Level: Guarded
• Score 11 and up
• Red = Severe
• Action:
- Assess the Patient
- Activate the Rapid Response Team
• Document:
- Patient assessed
- Rapid response activated
Best Practice Alert
• If a score has changed and an intervention has not been documented within the hour, a Best Practice Alert (BPA) will fire to alert the RN of the change in MEWS level.
• The BPA will only be triggered with escalating levels. (examples: Low to Guarded, or to Severe)
• Examples of BPAs:
BPA Actions
• Within the BPA actions can be documented by clicking
the “Document MEWS Interventions” link:
BPA Actions (Continued)
• The link will open this window, allowing the RN to document in real time.
Features of the BPA:
BPA Note
• A progress note can be created to document what interventions
were used. (It is not required). In order to do this:
1. Click “Create note”
2. Click “Insert Data” on Flowsheet Note pop-up
3. Write brief note and select “Sign”
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2
3
Required Documentation
• A MEWS Intervention needs to be documented once every 8 hours.
• MEWs Intervention has been added to the shift
required documentation.
Comprehensive MEWS Accordion
• Review MEWS specific documentation and trends by clicking MEWs intervention in the Required Documentation.
MEWS Report
• This a tool that can be used to review trends for the previous 48 hours.
Review of expectations
• Add MEWS column to your patient list
• Monitor MEWS scores using various tools:
- MEWS comprehensive accordion - MEWS report
- MEWS column
- MEWS in the flowsheet
• Document MEWS interventions once every 8 hours and as needed based on MEWS score
• Escalate patient condition as indicated
Case Study
42 year-old female comes in a for a planned knee
surgery. Post-op day #1 she is doing well and vital signs
are stable. Her MEWS is documented below:
Case Study
12 hours later the oncoming nurse noted that the MEWS was a 2 when taking report. On rounds it was noted that the score changed to 4.
Noting the change, the nurse prioritized the patient and went to see her next. The nurse found the patient sweating and cold and a little disoriented.
When reviewing the vitals, the following BPA was received and the nurse was able to document interventions in the BPA.
Case Study
• With a score of 4, the RN will recheck vital signs and assess the patient to identify a potential cause. If needing an intervention, the RN would proceed and recheck vitals signs or perform an
assessment to ensure the intervention is effective.
• Later the RN notes that the score has now jump to an 9. Next steps include:
- Assessing the Patient, who was disoriented and lethargic and had an increased temp, respiratory rate and HR.
- Notifying the Charge RN, who was able to page the MD and get the NA to sit with the patient while the RN left the room.
• The provider is expected to complete a comprehensive assessment of patient within 60 minutes; if provider is unable to get to patient within 60 minutes then activate the Rapid Response Team
• In this case, the RN was able to get the provider up to round on the patient and verify that the patient was septic and needed to start
antibiotics and needed fluids. The patient was able to remain on the unit with identified next steps and clear orders.
• 8 hours later the patient was back to a 3, alert, and walking the hallways
Summary
• MEWS is a tool that can assist in identifying decompensation early in a patient.
• MEWS will be used by most patient care areas as an added level of safety
• RNs are responsible for documenting MEWS interventions minimally every 8 hours and as needed based on customer presentation.
• MEWS should help us to prevent code blues
and assist in escalating concerns earlier.
Next Steps:
• The official go-live will be August 1, 2017
• Each RN will need to add the MEWS column to their patient list.
- Tip sheets on how to add a column will be sent out if unable to remember how to add.
• RNs will need to begin reviewing the MEWS
score and documenting interventions starting
at 10am August 1, 2017.
Resources
• Terra Erickson, Manager, NMHH
• Sarah Pangarakis, Critical Care CNS, NMHH
• Heather Singsank, Manager, NMHH
• Sandy Bremer, Assistant Clinical Manager MGH
• Sheryl Vugteveen, Manager, MGH
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