the Abstract

Problem There is a disconnect between PICU staff and Acute Care staff regarding patient acuity at transfer. The current process for handoff does not utilize a face-to-face communication, which can result in misunderstanding patient care needs. PICO Question Does using PEWS when patients are Continue reading the Abstract

RCHSD PEWS on CHEX – incomplete

Code Blue Resuscitation events continue to occur outside of the Critical Care Unit.

Objectives

  • To describe what PEWS is and how it is used.
  • To describe why PEWS can be a useful tool.
  • To accurately score a patient using PEWS
  • To indicate action steps for PEWS of 3 or higher.

PEWS is an assessment objective tool using 3 criteria that has been found to be reliable for early prediction of deteriorating patient status.

  • PEWS is utilized in non-critcal care areas.
  • A PEWS score is calculated with each patient assessment
  • A PEWS algorithm guides decision making and actions.

Rationale for PEWS Literature Review

One Study (Buist 1999) showed 76%  of arrests were preceded a period marked by clinical instability. The average period of instability prior to arrest was 6.5 hours. in a second study (Franklin & Matthew 1994)  66% of patients who arrested had abnormal S&S within 6 hours of arrest, but the MD was notified in only 25%.  In several studies retrospective chart review showed increased PEWS were evident as much as 24 hours prior to to a code or RRT. (Tucker et al 2008, Parshuram et al 2009, CHCA 2009)

Benefits of PEWS

PEWS improves collaboration and communication among providers. Improves confidence of bedside staff. Improves recognition of early patient deterioration and need for interventions. Improves escalation process for patient concerns. Improves reduction of preventable codes.

Retrospective Review of LCHSD Data

A review of 2009 LCHSD events reveal that 25% of the events had a critical PEWS score 2 – 13 hours prior to the code call. 59% of 2009 RRT activations had a critical PEWS 1-17 hours prior to activation.

Prospective Results from HemOnc Pilot

Code Blue on the HemOnc Unit decreased to 0 and RRT events increased

Rates per 1000 Patient DaysRRTCodes
0-3 months prior to PEWS0.70.35
0 - 3 months w/PEWS1.60.95
≥ 9-12 months w/PEWS1.510.0

PEWS is based on Normal Vital Sign Parameters

Standard Vital Sign Parameters

groupageResting HRResting RRSBPDBPMAP
newborn< 4 weeks120 - 16040 - 60
Infant< 1 y/o110 - 16030 - 40
Toddler< 3 y/o100 - 15025 - 35
preSchooler< 5 y/o 95 - 14025 - 30
School Age< 11 y/o 80 -12020 - 25
Adolescent< 17 y/o 60 - 10015 - 20

PEWS Algorithm – need to insert here

What if my patient is scoring ≥ 4 and MD has been notified?

After a provider assessment, a patient specific modification plan can be developed regarding notification of provider for increased PEWS Scores. For repeat scores of 4,5, or 3 in one category where the initial notification to the patient provider has occurred and an acceptable patient specific care plan has been established, repeat notification is not required.

What PEWS isn’t

PEWS does not replace subjective nursing and physician intuition or ‘gut feeling.”

A Rapid Response or Code Blue can be activated at any time the patient condition warrants and does not depend on the patient’s PEWS score.

You do not need permission to call a Code Blue.

Ways PEWS can be Used

  • PEWS can be used to balance patient care assignments.
  • PEWS can be used by providers to prioritize rounding.
  • PEWS can help guide patient placement, patient transfer, or discharge.
  • PEWS can help differentiate between stable and potentially unstable children.

Method of Implementation Here

  • PEWS are calculated each time vital signs are obtained
  • Unit PEWS data boards are updated q 4-6 hours
  • PEWS is utilized in charge RN meetings, shift report, rounds, resident sign off, transfers, and handoffs.

PEWS in Epic

Documentation

PEWS is documented from the Vital Signs, General Doc Flowsheet

PEWStidbit

The MD/NP comm row will have drop-down list to chose actions from. : 2nd RN Assessment, Charge RN assessed, MD notified, Interventions ordered, RT intervention, Transfer to higher level of care, RRT, Code Blue. Sidebar report has a hyperlink to the PEWS Algorithm. The scoring grid in not available, for unknown reasons, apparently none thinks anyone will need to consult it.

PEWS Data Goes in Patient List Add these three columns to your patient list. (Insert image here)

  • PEWS Score
  • A PEWS of 3 in a single category
  • Last PEWS Date and Time

PEWS Graph is available from the patient list

PEWS Report has been added to the Patient Summary Index


Patient is 17 m/o w/Hx of Sz. Video EEG in progress. Code called at 16:50, d/t Seizure.

  1. Calculate PEWS from the assessment prior to Code call. At 12:00 HR: 140, RR: 40, FiO2 =RA, mild retractions, pink, cap refill < 2, irritable, but consolable. 0, 1, 0, 1, 0, 0,  answer here
  2. What is appropriate action to take based on the algorithm?
    1. Consult with another RN to confirm the score.
    2. Reassess and rescuer with every VS assessment
    3. Consult with Charge RN and confirm score; notify HO/primary team.
    4. Reassess every 2 hours

    answer here

  3. Patient  8 y/o RRT activated @ 00:50. Calculate the PEWS score for the following assessment prior to the RRT call. VS @23:00 HR 155, RR 40, FiO2 40%, 4L NC, mild retractions, pink, cap refill < 2 sec,; irritable and not consolable. answer here
  4. What is appropriate action to take based on the algorithm?
    1. Consult with another RN to confirm the score.
    2. Reassess and rescuer with every VS assessment
    3. Consult with Charge RN and confirm score; notify HO/primary team.
    4. Notify the Charge RN immediately; Notify the Resident or Primary with mandatory urgent visit and call RRT.

    answer here

  5. If a patient has a score of 3 in one category, how often does PEWS need to be done? answer here


The Research Plan – AQHR style

Proposal / Protocol

Participants in Project: PICU and Floor Nursing Staff at the main campus of hospital.

“In highly successful change efforts, people find ways to help others see the problems or solutions in ways that influence emotions, not just thought” – Kotter

Implementation Plan

  1. Obtain Baseline Data
    • Before Intervention Survey of Nurses who will participate – for satisfaction scores.
    •  Historic frequency and rate of Bounce-backs for PICU transfers.
  2. Arrange for Changes to Epic flowsheets to facilitate documentation of PEWS
  3. Develop the Protocol for the Intervention
    • Make a model intervention, use it, evaluate, modify, rinse, repeat.
  4. Education of participants at team meetings and other gatherings of involved nurses
    • PICU RNs: Education on use of PEWS, the purpose, and intervention
    • Floor RNs: Education on the purpose, and intervention
  5. Begin Intervention
  6. at 90 days repeat surveys, and review data on bounce-backs

Outcome Measurement

  • Satisfaction – survey
  • Bouce Backs – Hospital Data on Return to PICU


Project Title

Use of PEWS at completion of handoff to Improve Nurse Satisfaction with Handoff, and to Clarify Patient Condition and Needs on Transition from PICU to the Floor.


Purpose Statement

The purpose of this project is improve nurse satisfaction with interactions between nurses from varying departments in the hospital, and to prevent harm to patients by transferring to floor  only when ready, to provide a handoff that prepares the receiving nurse and department to care for the patient at his current level of need.


PICO Question

Does a joint scoring of PEWS for patients transferring out of PICU to the floor, done at the time of arrival in the new room,  by the PICU RN and the receiving RN decrease bounce back to PICU as measured by bounce back frequency, and improve comity between nursing units as measured by nursing satisfaction scores ?


Background and Significance

Signify:

Patients returning to PICU after transfer may have been transferred without adequate handoff and suffered from inadequate care for their current condition. The


Methods: Subjects

group 1:Nurses working at main hospital in PICU , 2 Rose, 3 East, 4 East, HemOncGroup group 2: patients transferred from PICU to 2 Rose, 3 East, 4 East, HemeOnc

Process

  • Train PICU RNS to perform PEWS
  • Train Floor staff and PICU to perform and document  PEWS  – jointly , on arrival in new room

Outcomes

  • Measure the change in satisfaction by survey – Nurses
  • Measure the change in bounce backs – Patients

[/toggle]

Item 6 Title

Content for item 6


Item 7 Title

Content for item 7


QUESTIONS about This

What is the right collective term for Rose, 3&4 East, and HemeONc?  Is floor acceptable? Many studies use wards, but that is not part of our daily usage here. Non-PICU seems awkward, but so does the Floor.

what is the time interval that it would take till  50% of nurses in a department to have received a transfer fro PICU?  It might be more than a year.

About how many patients have you admitted to your unit from PICU in the last 6 months?
About how many patients have you admitted from PICU ever?
Did you receive a complete and accurate report
Did you perform a PEWS assessment with the sending RN
Did you have immediate complete agreement on the score?
If not, how was the difference resolved – probably shouldn’t ask that question
Were all the patients meds and equipment transferred
Thanks,
Chris