Ms. W, 75, admitted to your medical-surgical unit 2 days ago with a diagnosis of pneumonia has a week history of fever, chills, poor appetite, productive cough, and weakness. Her past medical history includes being an ex-smoker (2 packs a day for 48 years), hypertension controlled by one medication, abdominal hysterectomy 25 years ago, and no allergies. Yesterday, she had a cough and some pain with coughing, requiring 2 L of oxygen via nasal cannula to maintain her oxygen saturation at 98%. She was a bit confused, but her vital signs seemed within normal limits. When you go to introduce yourself and start your assessment today (day 3), you find she’s drowsy and lethargic, and she responds with one-word answers or grunts. You note that she’s using pursed lip breathing. You complete a set of vital signs and discover she’s febrile (100.2° F [37.9 C]), with a BP of 110/60; heart rate, 90 beats/ minute; respiratory rate, 24 breaths/minute; and oxygen saturation, 95% on 2 L of oxygen via nasal cannula.
What’s changed? Where is Ms. W’s condition taking her – the ICU or much worse? What signs did we miss that could have helped avoid a potentially poor outcome?
It’s not hard to understand the issue that adverse changes in patient condition are a major cause of poor patient outcomes. With increasing patient acuity levels, the push to discharge patients more rapidly, and the shortages of nursing staff make it challenging to provide high-quality care at the bedside. For example, every year in the United States, more than 45 million patients undergo inpatient surgical procedures. [i] Although most of these procedures are associated with minimal risk, at least 100,000 Americans die annually as a direct consequence of surgery. This doesn’t take in consideration those who experience serious complications and disability. [ii] Failure to recognize changes in a patient’s condition until major complications, including death, have occurred has to be addressed at the bedside and across the nation.
The key is to identify patients at risk. These patients may present with:
- An unstable medical condition (acute or chronic)
- A condition that is causing concern and requires increased frequency of observations
- An infectious process not responding well to treatment
- Post-operative course that is not progressing/improving
Patients presenting with these conditions, and others identified by your organization, will need frequent monitoring including vitals signs, oxygen saturation, level of consciousness and other established criteria to identify early decompensation that will necessitate intervention. It’s imperative to educate and involve your ancillary and nursing support staff who often have the most frequent contact with patients and can be critical in identifying changes in condition. The practice of good patient handoffs during shift change, unit transfers and with ancillary services (radiology, dialysis, etc.) is another process that can ensure changes in a patient’s baseline can be quickly identified.
Some organizations, many outside the U.S., utilize the Modified Early Warning System (MEWS) to identify patients in the early stages of deterioration through application of established scoring criteria in measuring vital signs, consciousness and urine output. In the late 1990’s the development of the Early Warning System (EWS) was founded on the discovery that many patients manifested subtle changes in their vital signs and other measures before a serious medical event such as cardiac arrest. This system has grown into the MEWS process that has demonstrated it can predict RRT and the need for ICU transfers up to 72 hours out. Vital signs and other clinical data in the MEWS is given a numerical score which is totaled and then categorized based on the scoring range. This provides guidance on interventions to follow including increased monitoring frequency, notification of provider staff, and possibly activation of the Rapid Response Team process.[iii] An example of a MEWS scoring criteria and response:
The Joint Commission has established standards that address the need for organizations to address adverse changes in patient conditions through assessment and reassessment. PC.01.02.01 asks, “Does the organization assess and reassess its patients?” This standard directs that organizations define in writing the scope and criteria for providing specialized and more in-depth assessments. PC.01.02.03 asks, “Does the organization assess and reassess the patient and his or her condition according to defined time frames?”[iv] This includes performing a reassessment for plan for care or changes in patient condition when necessary.
To support safe patient care, especially in avoiding adverse outcomes (including death), organizations must ensure staff are provided guidance in monitoring patients for early signs of deterioration. It has been established that subtle changes in patient condition are present prior to adverse clinical events, sometimes measured by days. Staff should ensure they are attuned to these changes and follow established protocols to support safe patient care and positive patient outcomes.
[i] Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;29:1-20, 24
[ii] Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010; 211:325-330.
[iii]MEWS Johnson S, Shenoy A (2017) Modified Early Warning Score: Does It Warn Enough. J Clin Med Ther Vol. 2 No. 2: 14.
[iv] The Joint Commission. (2017). Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission.