Year of Publication

2017

Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Debra Anderson

Clinical Mentor

Dr. Lerae Wilson

Committee Member

Dr. Nora Warshawsky

Committee Member

Dr. Cecilia Page

Abstract

PURPOSE: To develop and test a comprehensive modified early warning scoring (MEWS) system for use on two medical-surgical-telemetry units in a large rural hospital in northeastern Kentucky; to educate and train nursing staff in utilization of a new MEWS system and early identification and management of clinical deterioration; and to determine nursing satisfaction regarding education, training, and use of a new MEWS system.

BACKGROUND: Adult medical-surgical patients are at risk for clinical deterioration. Rapid response systems and MEWS systems are strategies that have been employed to assist nursing staff in early identification and management of clinical deterioration. Testing of a newly proposed comprehensive MEWS system and an educational intervention is an essential first step in determining interventional effectiveness.

STUDY DESIGN: A retrospective, single center, mixed methods observational study.

METHODS: In Phase I, retrospective chart reviews (RCRs) were conducted during a 6-month timeframe for patients meeting one of the following severe adverse event (SAE) criteria: in-hospital cardiac arrest, in-hospital death, unexpected transfer to the intensive care unit, and/or rapid response team utilization specifically pertaining to the medical-surgical-telemetry units of interest. Physiologic parameters (i.e., vital signs and level of consciousness) and nursing responses were recorded in the 24-hours leading up to SAEs; MEWS were retrospectively calculated at 24-hours (MEWS24), 16-hours (MEWS16), and 8-hours (MEWS8) to gauge utility of the MEWS tool. In Phase II, a 3-hour education and training workshop designed for nursing staff was developed, implemented, and evaluated. A focus was placed on use of a new MEWS system and early identification and management of clinical deterioration.

RESULTS: In Phase I of RCRs, 81 patients met criteria during a study timeframe of September 2016 through February 2017. Demographic data yielded the following: 51.9% male, 76.5% sixty years of age or older, and 98.8% White. MEWS24 (n = 62) had a mean of 3.0, standard deviation (SD) of 1.6, and range of 1.0 – 7.0; MEWS16 (n = 76) had a mean of 3.3, SD of 1.3, and range of 1.0 – 7.0; and MEWS8 (n = 81) had a mean of 5.0, SD of 2.3, and range of 1.0 – 10.0. In Phase II, nine nursing staff participated in one of eight education and training workshops. Participants reported increased confidence in recognizing deterioration, responding to deterioration, and communicating concerns following an educational intervention. Nursing staff consistently reported respiratory effort, level of consciousness, oxygen saturation, respiratory rate, blood pressure, and heart rate as the most influential parameters in a nursing assessment for determining clinical deterioration. Satisfaction was high regarding the education, training, and use of a new MEWS system.

CONCLUSION: RCRs indicated that a MEWS system would be feasible in identifying patients at risk for SAEs in this patient population. Introduction of a new comprehensive MEWS system with an educational intervention had a positive effect on nursing staff’s self-reported confidence, knowledge, and skill in recognizing and managing clinical deterioration.

RELEVANCE TO CLINICAL PRACTICE: Before full implementation, a prospective study is recommended to test a comprehensive MEWS system for all admissions through discharge over a defined time period and provide a mandatory educational intervention for interdisciplinary staff on the two medical-surgical-telemetry units of interest. Great insight could be learned regarding tool utility, resource utilization, and staff preparedness.

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