"'Early waring score' or 'track and trigger systems' aim to aid the timely recognition of patients with potential or established critical illness."




Fullerton, J., Price, C., Silvey, N., Brace, S., Perkins, G., (2012) Is the modified early warning score (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? Resuscitation 83. 557-562. doi: 10.1016/j.resuscitation.2012.01.004

6 Main is a busy, high-acuity unit. In addition cardio-pulmonary unit, it is an oncology overflow unit. Many of our patients were step-down from the ICU, or admitted from the ED not quite meeting the criteria to be sent to the ICU.

6 Main is also a teaching unit, so we have many interns and residents with which to collaborate.

This is the chart that I created to keep track of my patients for this project. I wrote the MEWS score in the grey column. The "notes" section about any interventions (or why no interventions were deemed necessary). For the purpose of convenience, I had two charts per page.

I learned very quickly that only one of our PCTs actually counted respirations. I did have to wonder that if they knew about the MEWS systen if they would have "guessed" a RR lower than 18 (since a RR of 18 gets you a 1 on the MEWS).

This has become such a habit for me that I find myself doing it several times per day with each of my patients. I use opportunities such as pushing IV meds to count respirations. I also count respirations whenever I'm observing a procedure or a doctor's examination.

I did not realize that my preceptor had picked on this until this past weekend. We were assisting another nurse whose patient was experiencing shortness of breath. While we quickly worked on getting him on oxygen, sitting him up, and taking vitals, one of the nurses called out, "Someone get respers." My preceptor replied,"Julia's got it."

80 year old female admitted with possible pneumonia. She had cardizem on board, which we gave her, and we called the physician. K runs were odered. Within an hour, her heart rate had dropped down to 83.

Unfortunately, this patient left AMA and I was unable to follow her progress.

69 year old female admitted for COPD exacerbation, and very involved in her own care. When morning vitals were taken [130/74, a 0 on the MEWS and all other vitals were normal as well], she asked what her blood pressure was and commented that this was high for her. I noted that she did not have history of high blood pressure and therefore had no blood pressure medication on board. At 2pm, her blood pressure had increased to 148/70. By 6m, she was 155/7 - still a MEWS score of 0, but I was concerned. I checked her again in 3 hours: 166/79.

I brought it to the attention of my preceptor, who had me report it oncoming shift. We recommended checking vitals q2-3 hours. I found out later that this patient's BP continued to climb and by 5:45AM the next day, she needed IV Lopressor to get it back down.

Of the 8 nurses I interviewed, none felt that they needed to use a MEWS score. Several nurses pointed out that with their COPD patients, an oxygen saturation of 90% would be considered good, but would automatically give that patient a MEWS score of 3.

I do agree that especially on specialty units, an adapted MEWS score may be more appropriate to decrease unnecessary calls to the Rapid Response Team.

I did some research to find out if any hospitals had done this.

In 2008, Northwestern Memorial Hospital in Chicago implemented an adapted MEWS specifically for their hem-onc units that included checking a lactate level when infection was suspected. This new MEWS score became part of the nursing and physician protocol (Young, Gobel, et al., 2013, p. 3).

"The implementation of a heme-onc protocol incorporating the MEWS and serum lactate level to trigger patient evaluation for decompensation and transfer to an ICU reduced code calls by approximately 50% and preventable codes by nearly 75%."

Young, R., Gobel, B., Schumacher M., Lee, J. Weaver, C., Weitzman, S. (2013). Use of the modified early warning score and serum lactate to prevent cardiopulmonary arrest in hematology-oncology patients: a quality improvement study. American Journal of Medical Quality. (1-8) doi
10.1177/1062860613508305

Did it increase my situational awareness?
Yes, definitely.

Did the use of the tool make me feel more secure about monitoring of the patient's condition?
Absolutely.

My plan as I continue to grow in my career and find my niche is to work to integrate a MEWS score adapted to the unit in which I am working.