GUIDELINE FOR THE USE OF THE MODIFIED EARLY WARNING SCORE (MEWS)

ONEL Guideline Ref 039 Page 1 of 13 Issue date June 2011 Review date June 2014

Policy Reference: Policy Title: Review Date: Approval: Author(s)/Further Information: Summary:

ONEL Guideline Ref 039 Guideline for the use of the Modified Early Warning Score (MEWS) June 2014 Governance and Standards Committee Geraldine Devaney, Productive Ward Lead, Inpatient Services Within ONELCS inpatient units the Early Warning Score and The Modified Early Warning Score (MEWS) are the two track and trigger scoring systems in use. The triggers are based on routine observations and are sensitive enough to detect subtle changes in a patients physiology which will be reflected in a change of score should the patient be improving or deteriorating. This guideline will be disseminated to staff via the Trusts internet in read only files. This is a mandatory risk management policy for the NHSLA Risk Management Standards accreditation.

Implementation: Impact:

Version Control Summary Version 1 Date June 2011 Status Ratified Comment Changes

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CONTENTS 1 2 3 4 5 6 7 8 Appendix A Appendix B Guideline Statement and Guiding Principles What are track and trigger warning systems? Why do we need Track and Trigger systems? When to use Track and Trigger systems Mews Training Monitoring and Audit Associated Policies References St Georges Inpatient Units Heronwood and Galleon Unit 4 4 5 5 6 7 7 7 8 12

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1.

Guideline Statement and Guiding Principles Outer North East London Community Services (ONELCS) Policies and Guidelines are produced in conjunction with the following vision, which underpins the development of the organisation. People are at the centre of what we are doing We can demonstrate a truly corporate spirit and collective responsibility We are clinically driven with managerial support We take responsibility for identifying and responding to need We seek to be fair and equal to all We seek to achieve our goals in partnership with others

2.

What are track and trigger warning systems? Within ONELCS inpatient units the Early Warning Score and The Modified Early Warning Score (MEWS) are the two track and trigger scoring systems in use. The triggers are based on routine observations and are sensitive enough to detect subtle changes in a patients physiology which will be reflected in a change of score should the patient be improving or deteriorating. All patients have their vital signs measured and these are converted into a colour coded risk band which documented on the front of the observation chart. The nearer to the red risk band the more abnormal the vital signs are. If the measurements reach above a certain threshold a doctor must be called to assess the patient. The system allows for the regular monitoring and recording of blood pressure, pulse, temperature, Glasgow Coma Score (GCS), AVPU, urine output and respiratory rate. Early warning scoring systems were originally developed with two specific aims: to facilitate timely recognition of the patients with established or impending critical illness; and to empower nurses and junior medical staff to secure experienced help through the operation of a trigger threshold which, if required, require mandatory attendance by a more senior member of staff. Use of a Modified Early Warning Scoring system can also: Improve the quality of patient observation and monitoring Improve communication within the multidisciplinary team Allow for timely admission to intensive care Support good medical judgement Aid in securing appropriate assistance for sick patients Give a good indication of physiological trends Are a sensitive indicator of abnormal physiology

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However, MEWS is not: 3. A predictor or outcome A comprehensive clinical assessment tool A replacement for clinical judgement

Why do we need Track and Trigger systems? Confidential inquiry into quality of care before admission to intensive care (McQuillan et al 1988) looked at why patients admitted from a ward area were much less likely to survive intensive care than those from A&E and theatres. The study found that: 41% of admissions to intensive care may have been avoidable if earlier intervention had occurred 69% of admissions to intensive care occurred late in the development if critical illness 54% of admissions had sub-optimal care prior to admission

The study highlighted the role of an early warning scoring system in the early recognition and management of high risk patients. A similar study by Stenhouse C. et al (2000) reviewed the use off an Early Warning Score over a 9 month period. The introduction of the system appeared to lead to earlier (and more appropriate) referral to intensive care. Both the Royal College of Surgeons and the Association of Anaesthetists of Great Britain and Ireland support the use of a MEWS system. The use of MEWS was also a significant recommendation of a recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD 2005) study and report. 4. When do we use Track and Trigger systems? Track and trigger systems rely on the routine recording and charting of the physiological status of the patient. These are simple observations that can be performed by a nurse, doctor or other trained staff. These observations include: Pulse Respiratory Rate Temperature Urine Output Blood Pressure SPO2
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Not all patients will require every part of the observation chart to be completed. Patients on admission to the ward will have their observations carried out and a MEWS score charted. The frequency and specifications of all observations should be prescribed in the nursing care plan. The following patients are considered to be at high risk of developing a critical illness therefore it would be considered good practice to commence the track trigger system at the earliest opportunity. This includes: All emergency admissions Unstable patients Patients whose condition is causing concern Patients requiring frequent or increasing frequency of observations Patients who have stepped down from a higher level of care Patients with chronic health problem Patients who are failing to progress

It may be necessary to assess a patient using the track and trigger system score prior to transferring them to another ward within the hospital or to an exterbal healthcare provider. If your patient is triggering the system consider any other factors you need to deal with prior to transfer. There are also patients in whom the use of a track and trigger system may be inappropriate. This includes: Patients who are terminally ill

This is not an exhaustive list. Although the majority of patients may benefit from utilisation of track and trigger system the clinicians own clinical judgement dictates whether he or she requires the patient to be regularly scored. Where the wards responsible doctors decision is that a track and trigger score is not appropriate, and then this should be clearly written onto the front of the observation chart. An annotation should also be made in the patient notes recording why the decision was made. 5. MEWS Training Medical staff receive information, instruction and training on the track and triggers system during their core curriculum training. Use of the individual units track and trigger forms will be discussed on induction.
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Nursing staff will receive information, instruction and training on the track and trigger system as part of local induction and as part of local ward/department training. Necessary, information on the use of Track and Trigger (and related incidents) will be highlighted to medical staff and raised at Senior Nurse meetings and Directorate Clinical Governance Committee meetings

6.

Monitoring and Audit An audit of implementation of track and trigger will be undertaken annually. Results of the audit will go to the Governance and Standards Committee. The Inpatient Services Department will review this guideline every 3 years unless a specific reason for an earlier review. Additional monitoring requirements can be found in the monitoring section of the Resuscitation Policy TP032

7.

Associated Policies Resuscitation Policy TP032

8.

References NCEPOD. 2005. An Acute problem? Stenhouse. C. Coates S., Tivey M., Allsop P., Parker T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. Br J. Anaesthesia. 20003: 84: 663P. McQuillan, Pilkington, Taylor, Short, Morgan, Nielsen, Barrett and Smith. (1998). Confidential inquiry into quality of care before admission to intensive care, BMJ, 1998, 316 (7148) 1853-1858. Sabbe C., Davies R., Williams E., Rutherford P., Gemmell L. (2003) Effect of introducing the modified Early Warning score on clinical outcomes, cardiointensive care utilisation in acute medical admissions. Anaesthesia, 2003 58 (8) 797-802. Williams W. eta l (2003) Outreach critical care-cash for no questions? British Journal of Anaesthesia, 2003 90 (5) 699-702.

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Appendix A St Georges Inpatient Units 1. Observation Chart

ONEL CS has implemented a standard MEWS system for use across all directorates and specialities. MEWS is incorporated within the Standard Observation Chart. 2. MEWS Score

Table 1
MEWS Score Temp (core) Pulse/Apex Systolic Blood Pressure Respiratory rate SPO2 CNS response (AVPU) Urine output 3 2 <35.0 <40 71-80 1 35.1-36.0 41-50 81 - 100 0 36.1-38.0 51-100 101 - 199 1 38.1-38.5 101-110 2 >38.6 111-130 >200 3 > 131

<70

<8 <85 85-89 New confusion /agitation <750ml/2 4 hours 90-93

9-14 >94 Alert

15-20

21-29

>30

Voice

Pain

Unrespon -sive

<500ml/ 24hours

1000-750 ml/ 24hours

AVPU is a simple assessment where A = Alert V = Responds to verbal commands only P = Responds to pain U = completely unresponsive . 3. Triggers Scores

A MEWS Score of 2 in ANY category indicates the need for close and frequent observation of the patient. A MEWS score of 4 and/or an increase of 2 or more indicates that the patient is potentially unwell and means that urgent medical attention is required. 4. How to respond to MEWS
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A MEWS Score must be calculated where a patient scores 2 or more in ANY observation category. At the initial stage MEWS observations should be calculated and recorded at hourly intervals (this may be changed to less frequent intervals after formal medical review of the patient). A MEWS of 4 or more and/or a MEWS Score increase of 2 or MUST trigger an urgent referral for medical review. During daytime hours, nursing staff should initiate a MEWS Call to the relevant ward Doctor. Out of hours this should be to the on call Doctor. If there is no response to the initial MEWS call within 10 minutes, nursing staff should re bleep the ward responsible Doctor and if there is still no response after a further 10 minutes, nursing staff should initiate a fast-bleep to the on call Register and on call Senior Nurse/Bleep holder. A member of medical staff MUST attend and assess the patient within 30 minutes, unless there are exceptional circumstances preventing a review by medical staff. NB: A failure to attend a MEWS call within an acceptable timescale (<30 mins) should result in the completion of a clinical incident form. A MEWS action plan must be agreed and documented for any patient reviewed. When there is no improvement with the patient within 1 hour, this must initiate immediate senior review and, if necessary emergency transfer to Relevant Accident and Emergency. 5. Out of hours reporting Out of hours a MEWS score of 4 or more and/or MEWS score increase of 2 or more MUST result in a Call to the on call Doctor and Senior Nurse/Bleep holder, who will also ensure that discussion on the management of a MEWS Trigger patient is formally discussed at the next handover. 6. Recording MEWS Observations and MEWS Scores MUST be recorded on the standard Observation Chart. The decision to initiate a MEWS call must be recorded in the patients notes. A standard MEWS Event Sticker (see Table 2) should be used for this purpose.

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Table 2: MEWS Event Sticker MEWS EVENT WARD: DATE: TIME: MEWS SCORE: NAME & GRADE OF 1ST RESPONDER: TIME SEEN: OUTCOME: If no response from 1st responder within 30 minutes, call ON-Site SHO/Registrar All notations in the patients notes (including inclusion of the MEWS Event Sticker) must be: - Legible - Signed - Dated - Timed - In Black ink

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ST GEORGES MEWS FLOWCHART Calculate MEWS Score

1-3

4+

MEWS Score Increases by 2

Inform SHO/ on call Senior Nurse/Bleep holder Inform HO/SHO ww wwllllllllll wwwwww (C Observe, repeat at appropriate intervals Record Bleep Ward SHO after 10 Minutes

Document all relevant details in medical ww notes (MEWS sticker in notes)

Fastbleep via Switchboard if no response from medical team in 10 minutes

Medical Officer attends within 30 mins

If no response within 30 minutes contact /call Senior Nurse/Bleep holder

MEWS action plan identified

If no improvement by patient within 1 hour

Senior Review Registrar Review

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Emergency Transfer

APPENDIX B HERONWOOD AND GALLEON MEWS POLICY

EARLY WARNING SYSTEM

Risk Band Urgent Warning Observe - At risk Normal Range 36.0 - 37.5 60-89 100 - 159 90-114 160-179 Observe - At risk Warning Urgent Temp (core) Pulse Systolic Blood Pressure <45 <80 <35.0 45-49 80-89 or >40 mmHg drop from normal <10 85-89 New confusion 90-93 <36.0 50-59 90-99 or >20drop from normal >38.0 115-129 180-199 >39.0 130 200

Respiratory rate Sp02 CNS response (AVPU) GCS Urine output (catheterised) Urine Output

<8 <85

10 - 19 94 Alert

20-24

25-30

>30

Voice

Pain

Unresponsive

10

11-12 <0.5 ml/kg/hr for 2 hours

13-14 <0.5 ml/kg/hr for 1 hour 1000-750 ml/24 hours

15 0.5 - 3 ml/kg/hr >3 ml/kg/hr

<500 ml/24 hours

<750 ml/24 hours

Normal Observe - at risk

Regular Observations Maintain frequent observations [2-4 hours] of high risk patients Inform nurse-in-charge immediately Implement first line treatment Increase frequency of observations to 1 hourly (TPR, BP, Sp02) Repeat medical / senior nurse review within 4 hours - if no improvement seek SENIOR advice or sooner if not improving, i.e. GP or PELC Continue 2 hourly observations until return to normal AND nurse-in-charge review Inform nurse-in-charge immediately Implement first line treatment Commence monitoring (BP, Sp02) Increase frequency of observations to 1 hourly until initial medical review Continue 1 hourly observations until condition stabalised Repeat medical / senior nurse review within 2 hours - if no improvement seek SENIOR advice or sooner if not improving, i.e. GP or PELC Maintain 2 hourly observations until return to normal AND nurse-in-charge review

Warning

Urgent

Inform nurse-in-charge immediately Implement first line treatment Commence monitoring (BP, Sp02, pulse, ECG) Commence 1/4 hourly until initial medical review Continue 1/2 hourly observations until condition stabalised Medical review within 1 hours - if no improvement seek SENIOR advice or sooner if not mproving, i.e. GP or PELC Maintain 1 hourly observations until return to normal AND nurse-in-charge review Transfer to A&E if no improvement
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Heronwood and Galleon MEWS Flowchart Calculate MEWS Score

Observe At Risk

Warning

Urgent

Inform Nurse immediately

Implement first line treatment

Increase frequency of observation to 1 hourly

Document all relevant details in medical notes

Repeat medical review/senior nurse review within 4 hours if no improvement seek SENIOR advice or sooner if not improving, i.e. GP or PELC

Continue 2 hourly observations until return to normal AND nurse- in charge review

Transfer to A&E if no improvement

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