28 Jan 2020

To improve sepsis outcomes, incorporate an Early Warning Scoring System into bedside care

By Cyndi Coyne, Clinical Consultant at Capsule Technologies

A recent study from the peer-reviewed journal The Lancet is both promising and concerning for patient safety when it comes to the early detection and treatment of sepsis. While sepsis deaths worldwide have dropped by 30 percent since 1990, the study also points out that an estimated 11 million people worldwide died with sepsis in 2017 alone — out of 56 million total deaths from all causes. That’s about 20 percent of all deaths.

The study’s researchers note the decline in sepsis deaths appear to be consistent with a worldwide effort to improve public health, including the “provision of clean drinking water and sanitation infrastructure and development of vaccines and effective antibiotics.” However, there’s a lot of room for improvement in the detection and treatment of sepsis.

There’s lots of evidence that demonstrates that mortality can be significantly reduced if septic patients are identified in the early stages of the disease progression. Monitoring a number of patient parameters, such as heart rate and respiratory rate, has led to the development of Early Warning Scoring Systems (EWSS) that assist healthcare providers to more readily identify changes over time while supporting hospital protocols for early sepsis detection.

Here are three key steps to reducing sepsis mortality rates in your hospital:

1. Establish protocol and follow through by measuring success rates

Most hospitals have established protocols to help detect if a patient is becoming septic. However, ensuring that protocol is consistently being followed by staff can remain a challenge. For example, recently I discovered how the University of Utah Health was not only incorporating Modified Early Warning System (MEWS) scores into the core of their sepsis monitoring protocol, but also that they have created a coalition to analyze if patient outcomes or key quality indicators have been positively or negatively affected since measures have been put in place.

The coalition wanted to ensure that their sepsis protocol was being initiated in a timely and consistent fashion with every patient, every time and followed through according to plan–with metrics to prove it. Prior to the MEWS initiative, they found that even with their protocol in place, they were still experiencing an unacceptable number of sepsis cases.

Not only is sepsis potentially devastating to patients, it’s also extremely costly to treat, causing unintended transfers to the Intensive Care Unit (ICU), extended hospital stays—and in some cases, even death. By taking a hard look at their program to see where they could make improvements in their sepsis protocol, University of Utah was able to not only improve sepsis outcomes through early detection, they also decreased the mortality rate for patients who experienced an elevated MEWS by 20 percent while cutting sepsis costs by 10 percent.

2. Conduct the MEWS at the bedside

Providers have long understood the benefits to patient care by having an early warning scoring system available in their electronic health record (EHR) systems. In fact, the success that University of Utah has achieved in reducing sepsis mortality rates can be largely attributed to incorporating a MEWS score in the patient record.

What if we could take early warning scores and patient monitoring one step further? What if an Early Warning Scoring System (EWSS) could be brought directly to the bedside? And not only the score but also the hospital protocol, including the specific actions to carry out, so there is no delay in initiating the proper interventions before leaving the room?

An EWSS score is an efficient, effective means of detecting a change in a patient’s condition early on when the right intervention can have the most impact. It’s particularly valuable for medical-surgical patients, who are not continually monitored. For example, with technology like Capsule’s EWSS, a score can be calculated and displayed at the bedside, along with the hospital protocol, so it can be acted upon immediately. While the score is also sent to the EHR, the advantage of using technology like, Capsule EWSS, the clinician collecting vital signs will be alerted with a pop-up on the screen if any data points required to calculate an early warning score are missing before it’s sent to the patient record. When the score lives and is computed in the EHR, there is no warning and either a score will not be calculated—missing an opportunity to assess a change in the patient’s condition—or the EHR may pull in the last measurement, which could be hours old, providing a score with questionable accuracy.

The advantage of an early warning score is its simplicity—a few data points that are routinely gathered that, when put together in one metric, has proven to be a reliable representation of the patient’s condition. If deployed with the right level of training and organizational support, it can be a very effective tool to identify patients at risk of serious decline in their condition and put the proper interventions in place early on so that the patient has the best chance of recovery.

For example, subtle changes to patients’ vital signs—such as respiratory rate or level of consciousness—often precede cardiac arrest and begin six to eight hours before patients begin to show signs of deterioration. Early identification of patients whose conditions are deteriorating can reduce admissions to the ICU as well as deaths.

3. Enable actionable insights for the care team from the bedside

Moving beyond early warning scores at the bedside, in instances where a patient is being continuously monitored, applying analytics to medical device data can provide a wealth of meaningful information that can be used in several ways. One way is helping clinical leaders better balance nursing workload to enhance job satisfaction and efficiency, ultimately leading to better patient outcomes. By automating the capture of patient vitals, nurse managers can use the information, along with other factors, to assess and assign team members more effectively. The result is a more balanced workload for each nurse, as this actionable data ensures that the highest acuity patients are not all assigned to the same clinical team.

Additionally, this can allow for true, real-time alarm surveillance, not just alarm management, that sends only meaningful, actionable alerts to frontline staff. It can be an extra set of eyes, watching all patients, all of the time, and provide a tap on the shoulder to the bedside nurse, to call attention to a potential problem brewing, hours before a serious event occurs. Further, many of these systems are vendor-agnostic and are interoperable with other technology platforms.

Through automation, alarm trends and thresholds are analyzed and presented, allowing decisions to be made that may reduce alarm fatigue. Often overwhelmed by the din of non-critical alarms, clinicians can suffer auditory fatigue and cognitive overload, which may affect their ability to discern alarms and alerts signaling a true emergency. Alarm fatigue has consistently been cited as a Top 10 Health Technology Hazard by the well-known healthcare analyst firm ECRI.

This is the future of EWSS: The right information at the right time to help clinicians make optimal decisions that improve patient outcomes.

Nearly every EHR in the marketplace today offers the ability to calculate an early warning score and, in some cases, recommend the appropriate actions for the provider to take. While certainly a step in the right direction, this approach can fall short because it requires a nurse or other healthcare provider to enter the EHR data necessary to calculate the score.

This process is also prone to delays and human error, and further requires providers to log in to the system to view the scores. Delays, even those that only last minutes, can make a major difference in the outcome for the patient—especially one that is already in a compromised or fragile state.

Using technology like the Capsule EWSS functionality of Capsule Vitals Plus and Capsule Chart Xpress, a care provider at the bedside can view the patient’s score and promptly intervene. The early warning score can also be sent to the networked alert system in order to inform other team members—whether that is the nurse assigned to care for the patient, the charge nurse, or even the rapid response team—improving communication and making staff aware of the elevated score and initiating a bedside visit and response. Accessing an early warning score at the point of care and having devices and applications sending alerts in near real time can have a positive impact on patient safety and, consequently patient outcomes.

To learn more about Capsule’s Early Warning Scoring System, click here.