Variability in care processes affects both care quality and patient safety. Nowhere is the result of this variability more concerning than in hospital mortality rates. Recent literature points to three main issues that contribute to the problem:

  • Failures in planning, including assessments, treatments and goals
  • Failure to communicate (patient to staff, staff to staff and staff to physician)
  • Failure to recognize deteriorating patient conditions

At Peninsula Regional Medical Center (PRMC), we decided to attack these challenges and improve the care of our patients by quickly identifying those with deteriorating conditions and applying a consistent process for appropriate intervention.

This process would enable us to reduce the number of “Code Blue” medical emergency responses to resuscitate a patient and avoid the mortality that often follows these events. By initiating proactive vs. reactive care, we believed PRMC could use health IT to help us hard-wire a consistent method for delivering timely care to patients at risk of mortality.

Empowering Proactive Care

To help us identify patients that are at risk for a Code Blue, we implemented Modified Early Warning Scores, or MEWS, supported by our clinical information technology. MEWS is an evidence-based scoring methodology that uses patient vital signs to predict and alert caregivers of a patient’s declining conditions so they can intervene.

In our MEWS project, the vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation and temperature) are gathered automatically from documentation already being done in the electronic health record (EHR). The data is analyzed behind the scenes by rules-based “if/then” clinical alerts to calculate a score. The MEWS score is used to drive a standard process of assessment for intervention.

Many institutions have proven the MEWS alerting system to be helpful, but very few have used an electronic method to deploy it. By having the score calculated automatically and introduced into the clinical workflow, caregivers can quickly intervene using a Rapid Response Team (RRT) call, when appropriate, versus having the patient deteriorate to an emergent condition. This intervention ultimately helps to reduce Code Blues, and the risk for poor outcomes and mortality associated with them, as well as unplanned transfers for critical care.


Health IT Leveraged to Alert on Deteriorating Patient Conditions

The MEWS score enables intervention before the deterioration requires the need for a Rapid Response team, or worse, the patient status goes to Code Blue.

Implementing with a Multidisciplinary Approach

To implement the project, we used the Define-Measure-Analyze-Improve-Control (DMAIC) approach to measure, implement and re-measure the effectiveness of the tool and our process. Project leaders included a multidisciplinary team of clinician leaders from across departments. The triggered alerts enabled us to improve our team approach to bedside care with accelerated information exchange between ancillaries.

Our MEWS project included improved documentation of the care plan and entry of vital signs by certified nurse aids, development of care alerts for deteriorating conditions, clinical documentation of assessment escalations and use of analytics to evaluate the clinical data.

Clinical staff was educated, and prior to go-live, behind-the-scenes inspectors performed preliminary workflow assessment and evaluated initial care alerts.

Achieving Results in Improved Quality and Reduced Cost

In the first three months of a pilot of the system on a nursing unit, there were no Code Blues or mortalities. Over a nine-month period, the unit saw a 67% decrease in Code Blues and a 76% increase in Rapid Response Team (RRT) calls, which meant that care teams were addressing changing patient conditions more promptly. The pilot also saw fewer transfers to an intensive care unit, indicating that interventions were preventing the need for transfers.

By being proactive versus reactive, we can prevent costs for additional care and an extended length of stay. We calculated our savings using estimates from a Minnesota hospital, which found that Code Blue survivors cost an additional $20,684 in care, and non-survivors cost an additional $3,329.

For Code Blues that occurred on the nursing unit prior to the MEWS initiative, we would have saved more than $400,000 for one nursing unit. For the nine-month nursing unit pilot, our 67% reduction in Code Blues translates to an estimated $2.3 million in savings. We estimate a potential savings of $3.2 million if we can prevent Code Blues altogether in the medical/surgical units. Since the pilot, PRMC is live on three more units, with continued reduction in Code Blues and an increase in rapid responses.

Continuing the Benefits of Proactive Care

The care alert is the key element to trigger the assessment and proactive plan of care. We have shown that the electronic MEWS results are repeatable, and the standard process we instituted has been culturally sustained. Because the score provides objective data, it becomes a source of truth for the caregiver.

Clinicians trust evidence-based data, and with the MEWS scoring and alerts, we can initiate care proactively, which improves patient outcomes and reduces costs through more effective use of intensive-care resources.

Peninsula Regional Medical Center (PRMC) is the winner of McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. This is the third time PRMC has won a McKesson award for its clinical improvements. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Results of MEWS Pilots at PRMC

Three-month deployment at a cardiac step-down unit:

  • No Code Blues

Nine-month pilot on nursing unit:

  • Seven of nine months without a Code Blue
  • Four consecutive months without a Code Blue
  • Average 48% increase in Rapid Response calls during nursing unit pilot
  • A 67% reduction in Code Blues, which translates to an estimated $2.3 million savings
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About the author

Dr. Snyder joined Peninsula Regional Medical Center (PRMC) in 2002 as a hospitalist, and currently is the chief medical information officer and chief quality officer. He also acts as the physician advisor for utilization review and case management, is involved in the development and implementation of a fully integrated clinical informatics system, and specializes in clinical data mining and physician engagement using evidence-based educational and informatics tools. He is an advisor to the National Quality Forum HITAC committee and the Maryland Health Information Exchange development board (CRISP). In 2010, he received the AMDIS award for his efforts in using clinical informatics to promote patient safety. In the same year, he was honored as one of the Top 25 Clinical Informaticists by Modern Healthcare magazine. Dr. Snyder represented PRMC in 2009, 2011 and 2013 when they won McKesson awards for clinical excellence.

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About the author

John Morcom has been a respiratory therapist for 42 years. He served as a critical care and senior therapist for 32 years before joining PRMC’s IT department, where he has worked for six years as a clinical analyst for McKesson ED and CPOE clinical solutions. In addition, he has served as director of respiratory services and the chairperson for PRMC’s Code Blue committee for the past three years. He also served as a clinical instructor for Salisbury University’s School of Respiratory Therapy for eight years.