1. Quality Improvement In Healthcare: Modified Early Warning System (MEWS)
Tracy Cornille, Joanna Gallano, Renee Schafer, Valerie Snapp, & Chester Wheeler

2. Objectives What is Quality Improvement in Healthcare How MEWS Works
Goals of MEWS
Scoring and Relevant Interventions
Efficacy of Pilot Studies
MEWS Scenarios
Guidelines for Performance Improvement Group Project
State the purpose and philosophy of quality management in health care and introduce your performance measure and the potential impact for professional nursing and the health of the population you serve.
Describe common methods used by health care facilities for assessing and improving this performance measure. Has this been done before or is it a new concept?
Identify at least 3 current research/publications concerning the issue being analyzed. This section should rely heavily on information published in refereed journals, authoritative websites, government and other publications. References should be current (within the last 5 years).
Identify one core processes or strategy to improve the quality and/or safety for this performance improvement measure.
Describe how you would implement this performance improvement measure and institute change
Differentiate between internal and external benchmark comparisons and how you would measure the success of this performance measure

3. Quality Improvement
Quality Improvement- is the goal for making refinements in practice that are based on efficacy and efficiency (Kearney-Nunnery, 2012, p.10)
Increase Efficiency
Reduce Healthcare related Costs and Waste of Time/Resources
Increase Patient Safety
Increase Positive Patient Outcomes
Increase Nurse’s Time at bedside
How can healthcare practices become more safer and efficient for both clinician and patient alike?
-Increase Efficiency:
QI changes results in operational system being more efficient in procedures, time, and safety for patients.
-Reduce Healthcare Costs
- More efficient systems lead to reduced health care expenses
-Increase Patient Safety:
-Implement systems of safety checks and balances to improve patient safety
-Increase positive patient outcomes:
- QI in health care leads to an increase in positive patient clinical outcomes and discharges
-QI ultimately leads to Nurse’s being able to spend more time at the bedside with patient providing care, executing more thorough assessments, implementing more timely interventions, and providing therapeutic care and communication.

4. MEWS Modified Early Warning System Each parameter is given a score
Scoring system based upon vital sign parameters
Level of Consciousness or Change in Mental Status, Temperature, Respirations, Systolic Blood Pressure, and (depending on facility) Oxygen Saturation and Urine Output
Each parameter is given a score
Normal parameters = 0
Abnormal parameters = 1, 2, or 3
Modifiable to each particular unit.
PACU = PEWS
Obstetrics = MEOWS
MEWS is integrated into each facility and unit with patient populations taken into consideration.

5. Goals of MEWS Increase Patient Safety Identify high risk patients
Physiological decline usually precedes critical illness onset (Steen, 2010)
Detect deteriorating patients earlier and call Rapid Response
Trained team of specialists with advanced life saving training that can implement clinical judgment and care.
Prevent Code Blues and mortalities
Historically, Rapid Response has been called when there is a significant change in a vital sign, or when the healthcare worker just felt “like something is not right.” MEWS allows for implementation of RR much earlier and ultimately this reduces the occurrence of code blues/cardiac arrests and deaths.

6. Goals of MEWS REDUCE COST
Peninsular Regional Medical Center MEWS Trial Unit 5E (Snyder, and Morcom, 2013)
Prior to MEWs on average of 2 codes per month = 24 yearly at an estimated cost of $3,330 per code. After MEWS implementation, there were only 2 codes in 6 months resulting in mortalities at an estimated cost of $6,660
Of the 24: 20% code blue mortality rate = 5 patients x 3,330 = $16,650
80% survival rate= 19 patients x $20,684 = $392,996
Peninsular Regional Medical Center: 3500 Employees •400 Community based physicians •21,000 admissions •90,000 ED visits •358 acute care beds
MEWS allows for earlier interventions on deterioarting patients, thereby decreasing the cost of code blues and mortalities.
MEWS estimated savings by preventing code blues is potentially 400K annually for just 5E only.

7. MEWS SCORING PARAMETERS3 2 1
Temp
<35.1
>38.5
Resp Rate
<9
9-14
15-20
21-29
>/=30
Heart Rate
<40
40-50
51-100
>130
Systolic BP
<71
71-80
81-100
>/=200
LOC
Unresponsive
Responds to Pain
Responds to voice
Alert
New Agitation/confusion

8. SCORING & INTERVENTIONS
Once the vitals are entered by the RN or Tech, computer software will alert the RN to the patient's total score. Some facilities use a color coded system to emphasize degree of concern or risk
0-2 GREEN
3 YELLOW
4 ORANGE
5 RED
PRMC MEWS system notifies a comprehensive team of MEWS specialists to verify score and ensure interventions are carried out appropriately. (Snyder, and Morcom, 2013.)
Original MEWS were tedious and handwritten. Integration of computer software has made tallying more accurate and more easily conveyed to specialists.

10. MEWS Effects on Nursing
MEWS enables nurses to know when to:
continue monitoring and perform routine care
increase monitoring of VS and when to inform others of changes in VS
When to notify the physician(s)
When to contact the RR team for help
Long term: Identify particular populations prone to triggering system: Sepsis, Resp Failure

11. MEWS ORIGINS: EWS
Derived from the Early Warning System implemented in Europe, MEWS is rather new in the United States.
Ysbyty Gland Clwyd (YBC), a 900 bed acute care hospital located in Central North Wales, as a part of the Institute for Healthcare Improvement's Safer Patients Initiative (SPI), has been using MEWS for many years now.
The SPI is actively working to improve the quality and safety of health care in the UK by encouraging the uptake and spread of best practices (Early Warning Systems: Scorecards That Save Lives, 2014, p. 2).
One of the first pilot hospitals YBC:

12. Pilot Studes
2008 Mercy Hospital Anderson, Cincinnati, Ohio 252 bed acute care hospital, 9 month pilot (Snyder, and Morcom, 2013)
50% decrease in Code Blues per 1000 patient days
110 % increase in Rapid Response per patient days
2012 Peninsula Regional Medical Center, Salisbury, Maryland, Unit 5E, 42 bed Med/Surg, 9 month pilot (Snyder, and Morcom, 2013)
67% decrease in code blues per 1000 patient days
76% increase in Rapid Response per 1000 patient days
PRMC: had 4 consetive months without a code blue and 7 of 9 months without a code blue.
Vital signs accuracy have increased with MEWS implementation because there is a greater expectation for accurate and timely entry of vitals.
Staff satisfaction is improved, they are being proactive vs reactive (Fiscal Report 2013 Peninsula Regional Medical Center, 2013).

13. Implementing MEWS
YGC provided laminated cards for all nursing staff as well as monthly educational meetings on MEWS
PRMC in Maryland: Staff Education (Nursing, Ancillary and Physician):
Net learning
Story Boards
Articles in department publications
Presentation to staff at department meetings
Go-Live Support
Education at Munroe Regional was done on a unit to unit basis after a successful pilot on Medical Surgical
No official data available for Munroe Regional, but rapid response calls have increased significantly in the last few months since MEWS implementation.
Education, education, education.
Overcoming longhelf beliefs from staff about their competency to function; “I know better than this, “ “we don’t need to document this, we already know when to call RR.”
Other obstacles: Inaccurate vital sign entry leads to false results; and incorporating MEWS into existing software programs=IT logistically issue.

14. SCENARIO 1
You walk into the patient's room shortly after shift change. He is asleep and doesn't startle while you adjust the blood pressure cuff on his arm. You say good morning a few times until he finally opens his eyes and responds back a garbled " good morning" and closes his eyes again.
Vitals are as follows: T- 38 C RR- 20 HR-98 BP-150/85
What is his MEWS and what are your interventions?

15. 2 MEWS & INTERVENTIONS Interventions: ???? T- 38 = 0 RR- 20=1 HR-98 =0
BP-150/85=0
Responds to Voice = 1
Interventions: ????
Interventions: continue to monitor

16. SCENARIO 2
It's been two hours and you go back to reassess the patient and get a new set of vitals. You find him restless in the bed, pulling at his wires and IV tubing. You get him to settle a bit and take a new set of vitals.
Vitals are as follows : T - 38 C RR- 28 HR-100 BP-90/60
What is his MEWS and what are your interventions?

17. 4 MEWS & INTERVENTIONS T - 38 C = 0 RR- 28 = 2 HR-100 =0 BP-90/60 =1
New Agitation/Confusion = 1
Interventions: ????

18. SCENARIO 3
Patient is 2 days ago post right hemicolectomy HR 121, R 22, Temp 38.7 C, Alert
What is the MEWS scores and interventions?

19. 6 MEWS & INTERVENTIONS HR 121=2 R 22=2 Temp 38.7 C= 2 Alert = 0

20. Literature Review of MEWS
Kyriacos, Jelsma, & Jordan (2011) Literature Review of MEWS Systems: Of 534 papers reporting MEWS/EWS systems for adult inpatients identified, 14 contained useable data on development and utility of MEWS/EWS
“Better monitoring of patients implies better care, but searches indicate that the impact of vital signs monitoring and MEWS/EWS systems has yet to be tested in large, randomized controlled clinical trials. Nevertheless, there is sufficient evidence from observational work that MEWS/EWS systems facilitate recognition of abnormal physiological parameters in deteriorating patients, alerting ward staff to the need for intervention.”

21. REFERENCES
Carle, C., Alexander, P., Columb, M., & Johal, J. (2013). Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia, 68(4), doi: /anae.12180
Early Warning Systems: Scorecards That Save Lives (2014). Retrieved from
Kearney-Nunnery, R. (2012). Advancing Your Careeer. Philadelphia, Pennsylvania: F. A. Davis Company.
Kyriacos, U. U., Jelsma, J. J., & Jordan, S. S. (2011). Monitoring vital signs using early warning scoring systems: a review of the literature. Journal Of Nursing Management, 19(3), doi: /j x
Snyder, C., & Morcom, J. (2013, January 1). Predicting Care Using Informatics. Retrieved October 5, 2014, from regional medical center daa final presentation.pdf