Early Warning Scores (EWS): A patient safety quality improvement project at a tertiary hospital in UAE

By Dr. Wissam Abdul Hadi, Chief Quality Officer, NMC Royal Hospital Cluster, Khalifa City, Abu Dhabi, UAE

Early Warning Scores (EWS) are commonly used in acute care hospitals to detect early signs of patients that are medically deteriorating to have timely intervention by multidisciplinary medical teams to reduce morbidities and mortalities; reduce admissions to Intensive Care Units (ICUs); improve patient safety, clinical outcomes; and patient and family experience. Several studies demonstrated that patients before dying or going into a cardiac arrest are commonly preceded by several hours of deranged physiology.

The EWS scoring system is based on physiological measurements: respiratory rate, oxygen saturation, temperature, systolic blood pressure, heart rate and level of consciousness. Each measure is scored from 0 to 3 and added together to give an overall score with an additional two points for supplemental oxygen. Based on the score, medical intervention will be formulated to care for the patient; examples include putting the patient under frequent observation to admitting the patient to ICU.

For implementing the EWS, a multidisciplinary team of physicians and nurses was formulated and started researching the internationally published references and forms on EWS. It was decided to adapt one of them to avoid reinventing the wheel. The adapted EWS Policy and related forms were modified resulting in having a draft that meets the hospital criteria, needs and population it serves; ranging from neonates to adults taking into consideration special services at the tertiary hospital like Obstetrics and Gynaecology and Long-Term Care, which requires a modified EWS.

Having this as a Quality Improvement (QI) project in the patient safety domain pilot testing was conducted for three months using the Plan-Do-Study-Act (PDSA) cycle across all inpatient units excluding the ICUs. Data was gathered and the draft of the EWS Policy and related forms were revised based on the feedback gathered. That was the first PDSA cycle. Then the second PDSA cycle was initiated to pilot test the changes done on the first version of the draft of the EWS Policy and related forms for another three months. Again, data was gathered and the EWS Policy and related forms were revised for the second time based on the feedback gathered. A third PDSA cycle was initiated to pilot test the changes done on the second version for another three months. Once more, data was gathered and the draft of the EWS Policy and related forms were revised for the third time based on the feedback gathered. Finally, a fourth PDSA cycle was initiated to pilot test the changes done on the third version for another three months, which ended up in endorsing the third version. This process took about nine months to ensure that the EWS system is sound, in line with international standards, and helpful to staff. Staff engagement in this project helped a lot in the buy-in, which is very crucial to implement any new system or programme.

The hospital staff was involved in choosing the name of the multidisciplinary team that will respond to the EWS activation. They had to choose between ‘Rapid Response Team (RRT)’ or ‘Medical Emergency Team (MET) call’ and they decided to have it as MET call, which comprised of an in-charge nurse, General Practitioner and an Intensivist.

Afterwards, an education and training campaign was initiated to all concerned staff at the inpatient units to help in the EWS implementation. Constant feedback and support were given to staff to ensure correct implementation and maintaining the practice. The clinical leadership always encouraged the clinical staff to activate the MET call whether by the nurses or physicians when necessary, and even when they have doubts or feel uncertain.

The initial results of three months implementation showed a 45 per cent reduction in the number of code blue activations and transfers to ICU.

Having noted all of the above, this doesn’t necessarily mean that all sick patients will be captured by the EWS as the physiologic measurements may not fall within the pre-determined high-risk values of the EWS. Staff initially were hesitant to call the physicians to avoid any inconvenience or potential ‘trouble’. Other challenges included things like, nurses didn’t record the right physiological measurements or totally forgot to document it and didn’t activate the EWS and call the MET call team.

Success factors
The key success factors in the implemented EWS system were having debriefs following the MET call team response to any call. Also, all feedback gathered from all MET calls’ activations were discussed in the Code Blue Committee, which regularly shared the feedback on any changes required and good practices to improve and maintain the implementation of the EWS system. Additionally, the MET call team served as a resource and support to the medical team. Finally, support and respect from management and medical team regardless of whether the MET call was real/valid or unreal/invalid. One must have the attitude that this is a learning experience to sharpen the clinical skills of staff to better serve the patients and keep them safe.

Areas for improvement
Some of the things that can be done to improve the EWS implementation is to have an automated one. All the physiological measurements that are needed for the EWS can be accurately captured by an electronic system that can be configured to do the calculations and give the staff an idea about what actions to take. Reducing the human intervention can help in reducing errors due to manual data entry errors and miscalculations. On the other hand, the team will need to keep in mind that having an automated system could have some errors due to the automaton that needs to be managed before implementing it.

Implementing an EWS is a very important hospital initiative. It’s a learning journey with some challenges, but with the right tools, support, and team members, it can make a significant difference for both clinical teams, patients, and their families. It reduces mortalities, morbidities, admissions to ICU and code blue activations. And very importantly it will make the staff feel supported, and it will keep the patients and their families safe.

Dr. Hadi will be speaking on “Implementing an Early Warning Score System: A quality improvement project” on October 25, day two of the Patient Safety conference, at Patient Safety Middle East.