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Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores.

ABSTRACT: Introduction:Accurate and timely documentation of pediatric early warning scores (PEWS) by the bedside nurse into the electronic health record (EHR) is important to promote early identification of patients in stages of deterioration. Through the implementation of a PEWS calculator embedded in the EHR, we hope to improve the accuracy of the recorded score and reduce the time between vital sign collection and final documentation in the EHR. Methods:Identification of the highest PEWS value in the 24 hours before all unplanned transfers or rapid response activations without a transfer occurred between the period November 1, 2013, through December 31, 2016. The accuracy of the calculated cardiac or respiratory subscore based on heart rate or the respiratory rate at the time of PEWS calculation was determined. We tracked the calculation of the time to chart via the difference between nursing documentation of PEWS compared to vital sign collection. Before September 3, 2015, PEWS was calculated mentally by the bedside nurse; afterward, the nurse entered the unique PEWS features into the EHR, and the EHR automatically calculated PEWS. Results:This study evaluated 2,409 PEWS scores, 1,411 before and 998 after initiation of the PEWS calculator. Accuracy before the EHR calculator was 71%, and the median time to document was 55 minutes. Following the implementation of the calculator, no scores were incorrectly calculated too low, and the median time to document was 20 minutes. Conclusions:Transition to an EHR-based PEWS calculator eliminated inaccurately low PEWS values and reduced time to document.

SUBMITTER: Dean NP

PROVIDER: S-EPMC7190257 | biostudies-literature | 2020 Mar-Apr

REPOSITORIES: biostudies-literature

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Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores.

Dean Nathan P NP Cheng Jenhao J JJ Crumbley Ian I DuVal Jennifer J Maldonado Eliana E Ghebremariam Emanuel E

Pediatric quality & safety 20200325 2

<h4>Introduction</h4>Accurate and timely documentation of pediatric early warning scores (PEWS) by the bedside nurse into the electronic health record (EHR) is important to promote early identification of patients in stages of deterioration. Through the implementation of a PEWS calculator embedded in the EHR, we hope to improve the accuracy of the recorded score and reduce the time between vital sign collection and final documentation in the EHR.<h4>Methods</h4>Identification of the highest PEWS ...[more]

PMID: 32426641

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Project description:Background: Early Warning Scores (EWS), including the National Early Warning Score 2 (NEWS2) and Modified NEWS (NEWS-C), have been recommended for triage decision in patients with COVID-19. However, the effectiveness of these EWS in COVID-19 has not been fully validated. The study aimed to investigate the predictive value of EWS to detect clinical deterioration in patients with COVID-19. Methods: Between February 7, 2020 and February 17, 2020, patients confirmed with COVID-19 were screened for this study. The outcomes were early deterioration of respiratory function (EDRF) and need for intensive respiratory support (IRS) during the treatment process. The EDRF was defined as changes in the respiratory component of the sequential organ failure assessment (SOFA) score at day 3 (ΔSOFAresp = SOFA resp at day 3-SOFAresp on admission), in which the positive value reflects clinical deterioration. The IRS was defined as the use of high flow nasal cannula oxygen therapy, noninvasive or invasive mechanical ventilation. The performances of EWS including NEWS, NEWS 2, NEWS-C, Modified Early Warning Scores (MEWS), Hamilton Early Warning Scores (HEWS), and quick sepsis-related organ failure assessment (qSOFA) for predicting EDRF and IRS were compared using the area under the receiver operating characteristic curve (AUROC). Results: A total of 116 patients were included in this study. Of them, 27 patients (23.3%) developed EDRF and 24 patients (20.7%) required IRS. Among these EWS, NEWS-C was the most accurate scoring system for predicting EDRF [AUROC 0.79 (95% CI, 0.69-0.89)] and IRS [AUROC 0.89 (95% CI, 0.82-0.96)], while NEWS 2 had the lowest accuracy in predicting EDRF [AUROC 0.59 (95% CI, 0.46-0.720)] and IRS [AUROC 0.69 (95% CI, 0.57-0.81)]. A NEWS-C ≥ 9 had a sensitivity of 59.3% and a specificity of 85.4% for predicting EDRF. For predicting IRS, a NEWS-C ≥ 9 had a sensitivity of 75% and a specificity of 88%. Conclusions: The NEWS-C was the most accurate scoring system among common EWS to identify patients with COVID-19 at risk for EDRF and need for IRS. The NEWS-C could be recommended as an early triage tool for patients with COVID-19.

Project description:ObjectivesAdministrative and clinical efforts to improve hospital mortality and intensive care utilization commonly focus on patient rescue, where deteriorating patients are systematically identified and intervened upon. Patient rescue is known to depend on hospital context inclusive of technologic environment, structural features, and hospital organizational behavioral features. With widespread adoption of electronic medical records, early warning score (EWS) systems, which assign points to clinical data elements, are increasingly promoted as a tool for timely patient rescue by referencing their prediction of patient deterioration. We describe the extent to which EWS intervention studies describe the hospital environment of the intervention-details that would be critical for hospital leaders attempting to determine the real-world utility of EWSs in their own hospitals.Data sourcesWe searched CINAHL, PubMed, and Scopus databases for English language EWS implementation research published between 2009 and 2021 in adult medical-surgical inpatients.Study selectionStudies including pediatric, obstetric, psychiatric, prehospital, outpatient, step-down, or ICU patients were excluded.Data extractionTwo investigators independently reviewed titles/abstracts for eligibility based on prespecified exclusion criteria.Data synthesisWe identified 1,434 studies for title/abstract screening. In all, 352 studies underwent full-text review and 21 studies were summarized. The 21 studies (18 before-and-after, three randomized trials) detailed 1,107,883 patients across 54 hospitals. Twelve reported the staff composition of an EWS response team. Ten reported the proportion of surgical patients. One reported nursing ratios; none reported intensive care staffing with in-house critical-care physicians. None measured changes in bed utilization or availability. While 16 qualitatively described resources for education/technologic implementation, none estimated costs. None described workforce composition such as team stability or culture of safety in the hospitals.ConclusionsDespite hundreds of EWS-related publications, most do not report details of hospital context that would inform decisions about real-world EWS adoption. To make informed decisions about whether EWS implementation improves hospital quality, decision-makers may require alternatives such as peer networks and implementation pilots nested within local health systems.

Project description:ImportanceEarly warning scores (EWSs) are designed for in-hospital use but are widely used in the prehospital field, especially in select groups of patients potentially at high risk. To be useful for paramedics in daily prehospital clinical practice, evaluations are needed of the predictive value of EWSs based on first measured vital signs on scene in large cohorts covering unselected patients using ambulance services.ObjectiveTo validate EWSs' ability to predict mortality and intensive care unit (ICU) stay in an unselected cohort of adult patients who used ambulances.Design, setting, and participantsThis prognostic study conducted a validation based on a cohort of adult patients (aged ≥18 years) who used ambulances in the North Denmark Region from July 1, 2016, to December 31, 2020. EWSs (National Early Warning Score 2 [NEWS2], modified NEWS score without temperature [mNEWS], Quick Sepsis Related Organ Failure Assessment [qSOFA], Rapid Emergency Triage and Treatment System [RETTS], and Danish Emergency Process Triage [DEPT]) were calculated using first vital signs measured by ambulance personnel. Data were analyzed from September 2022 through May 2023.Main outcomes and measuresThe primary outcome was 30-day-mortality. Secondary outcomes were 1-day-mortality and ICU admission. Discrimination was assessed using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC).ResultsThere were 107 569 unique patients (52 650 females [48.9%]; median [IQR] age, 65 [45-77] years) from the entire cohort of 219 323 patients who used ambulance services, among whom 119 992 patients (54.7%) had called the Danish national emergency number. NEWS2, mNEWS, RETTS, and DEPT performed similarly concerning 30-day mortality (AUROC range, 0.67 [95% CI, 0.66-0.68] for DEPT to 0.68 [95% CI, 0.68-0.69] for mNEWS), while qSOFA had lower performance (AUROC, 0.59 [95% CI, 0.59-0.60]; P vs other scores < .001). All EWSs had low AUPRCs, ranging from 0.09 (95% CI, 0.09-0.09) for qSOFA to 0.14 (95% CI, 0.13-0.14) for mNEWS.. Concerning 1-day mortality and ICU admission NEWS2, mNEWS, RETTS, and DEPT performed similarly, with AUROCs ranging from 0.72 (95% CI, 0.71-0.73) for RETTS to 0.75 (95% CI, 0.74-0.76) for DEPT in 1-day mortality and 0.66 (95% CI, 0.65-0.67) for RETTS to 0.68 (95% CI, 0.67-0.69) for mNEWS in ICU admission, and all EWSs had low AUPRCs. These ranged from 0.02 (95% CI, 0.02-0.03) for qSOFA to 0.04 (95% CI, 0.04-0.04) for DEPT in 1-day mortality and 0.03 (95% CI, 0.03-0.03) for qSOFA to 0.05 (95% CI, 0.04-0.05) for DEPT in ICU admission.Conclusions and relevanceThis study found that EWSs in daily clinical use in emergency medical settings performed moderately in the prehospital field among unselected patients who used ambulances when assessed based on initial measurements of vital signs. These findings suggest the need of appropriate triage and early identification of patients at low and high risk with new and better EWSs also suitable for prehospital use.

Project description:BackgroundPediatric early warning (PEW) scores represent a "track-and-trigger system" that identifies clinical deterioration in a patient's condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians.ImplementationThe PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool.EvaluationThe PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses' knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses' feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support.DiscussionImplementation of PEW scores increased nurses' technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.

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Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores.

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Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores.

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