- Email: [email protected]
Long-term effect of introducing an early warning score on respiratory rate charting on general wards
Resuscitation 65 (2005) 41–44
Long-term effect of introducing an early warning score on respiratory rate charting on general wards夽 Jackie McBride, Debbie Knight, Jo Piper, Gary B Smith∗ Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK Received 29 September 2004; accepted 23 October 2004
Abstract The respiratory rate is an early indicator of disease, yet many clinicians underestimate its importance and hospitals report a poor level of respiratory rate recording. We studied the short- and long-term effects of introducing a new patient vital signs chart and the modified early warning score (MEWS), which incorporates respiratory rate on the prevalence of respiratory rate recording in six general wards of our hospital. Prior to the commencement of the study, the average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5 ± 13.5%. After the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to three wards, this rose to 68.9 ± 20.9%. When all six wards had been using both the new chart and the MEWS system for almost 1 year, the figure had reached 91.2 ± 5.6%. During the pre-introduction period, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%; p = 0.118). During the second two audit periods, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (p < 0.001). The study confirms the long-term beneficial effect of introducing the MEWS system on respiratory rate recording into the general wards of our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This may have an impact on the future incidence of potentially avoidable cardiac arrest, deaths and unanticipated intensive care unit admission. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Breathing; Monitoring; Prevention; Respiration
1. Introduction The recording of a patient’s respiratory rate should be a routine component of clinical monitoring, as the respiratory rate is altered by numerous clinical states. These include shock, pain, cardiac failure, asthma, respiratory infection, drug administration and intoxication, cerebrovascular accidents, renal failure and diabetic ketoacidosis. The respiratory rate is also a component of the systemic inflammatory response syndrome (SIRS) [1], and is an important predictor of cardiopulmonary arrest [2,3] and readmission to a critical care unit [4]. Despite this, many clin夽 A Spanish and Portuguese translated version of the Abstract and Key-
words of this article appears at 10.1016/j.resuscitation.2004.10.015. ∗ Corresponding author. Tel.: +44 23 92286844; fax: +44 23 92286967. E-mail address: [email protected] (G.B. Smith). 0300-9572/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2004.10.015
icians underestimate the importance and usefulness of respiratory rate monitoring and recent reports demonstrate a poor level of respiratory rate recording in general hospital wards [5–10]. A range of early warning systems, which include the routine measurement of respiratory rate as a component, have been introduced in recent years to assist in the early detection of patient deterioration [11–17]. It might be anticipated that the introduction of such a scoring system would have an influence on the prevalence and frequency of respiratory rate recording. We have studied the effect of introducing a new patient vital signs chart and an early warning scoring system – the modified early warning score (MEWS) [13] – to a group of general wards in our hospital and have monitored their shortand long-term effects on the prevalence of respiratory rate recording.
42
J. McBride et al. / Resuscitation 65 (2005) 41–44
2. Method
3. Results
In September 2002, we introduced a new vital signs chart and the MEWS system to wards in our hospitals. To provide an indicator of their impact, we audited the prevalence of respiratory rate monitoring in the periods before and after their introduction. Baseline respiratory rate auditing commenced 17 weeks before the charts and MEWS was introduced (audit period 1); the baseline audit was continued for 5 weeks. Data were obtained from six general wards — two orthopaedic (A and D), two surgical (B and E) and two medical (C and F). On each day of the audit period, each ward was visited by one of the authors at approximately the same time each day. On each ward, the vital sign charts of the patients in 10 beds were scrutinised for evidence that at least one respiratory rate recording had been made in the prior 24 h. On each day, the beds chosen for audit were identical on each ward, but were varied on a daily basis. Beds that were empty at the time of audit were noted, but excluded from the final data analysis. The number of occupied beds, and the number of patients with at least one respiratory rate recording in the prior 24 h, were recorded for each ward on a daily basis and the totals summed for the whole audit period. The percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h was then calculated for each ward. On week 17 of the study, a new vital signs chart was introduced to all six wards. Each chart included a MEWS table and a section in which modified early warning scores could be documented. Nursing staff working on wards A, B and C were trained in the use of MEWS and the new vital signs chart during formal and informal training sessions lasting up to an hour. Members of staff on wards D, E and F were trained to use the new chart, but were instructed to disregard the MEWS system. Doctors were informed that not all wards would be capable of providing a MEWS. There was no overt transfer of nursing staff between wards during the study period. For the purpose of analysis, those wards where the vital signs chart and the MEWS system were both introduced at the start (A, B and C) were designated Group 1. Wards D, E and F, where the introduction of the new vital signs chart was the only initial intervention, were designated Group 2. Six weeks (week 23) after the introduction of the charts, the prevalence of respiratory rate monitoring on all wards was re-audited (audit period 2); the audit lasted for 7 weeks. From week 37, for approximately 4 weeks, nursing staff on wards D, E and F were trained in the use of MEWS. In week 67, 68 and 69, the prevalence of respiratory rate recording was again audited (audit period 3). Differences in respiratory rate prevalence between different time periods were compared using chi-squared (χ2 ) tests and Fisher’s exact test.
In audit period 1, prior to the introduction of the new vital signs chart and MEWS system, the total number of occupied beds in the six wards was 1251. The average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5 ± 13.5%. In audit period 2, i.e., after the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to wards A, B and C, the total number of occupied beds in the six wards was 1234; the average percentage where at least one respiratory rate recording had been made rose to 68.9 ± 20.9%. In audit period 3, when all six wards were using both the new chart and the MEWS system, the total number of occupied beds was 600 and the average percentage where at least one respiratory rate recording had been made reached 91.2 ± 5.6%. There was a statistically significant increase in the prevalence of respiratory rate recording between audit periods 1 and 3 (Fisher’s exact test, p < 0.0001). Table 1 shows the individual ward data for each audit period. The data show a clear rise in the percentage of occupied beds where at least one respiratory rate recording had been made for each ward during the study period. Fig. 1 demonstrates the data for each specialty group. During audit period 1, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%) (chi-squared (χ2 ), p = 0.118). During audit periods 2 and 3, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (chi-squared (χ2 ), p < 0.001). Table 1 The percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for each ward Ward
Audit period 1
2
3
A B C D E F
15.0 25.5 14.7 36.4 37.1 48.5
71.6 85.3 87.2 49.0 37.4 82.8
86.1 89.1 99.0 92.0 84.7 96.0
Fig. 1. Trend in percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for three different specialties.
J. McBride et al. / Resuscitation 65 (2005) 41–44
Fig. 2. Trend in percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for Groups 1 and 2.
Fig. 2 shows the independent effect of introducing the new vital signs chart and MEWS. At baseline (audit period 1), there was a significant difference (Fisher’s exact test, p < 0.0001) between the two groups of wards (Group 1, 18.4%; Group 2, 40.7%). In the second audit period, i.e., after the introduction of the new vital signs chart to all six wards, the average percentage of occupied beds in which at least one respiratory rate recording had been made was 56.4% for Group 2 wards. However, the average percentage for those in which MEWS had also been introduced (Group 1) had risen to 81.4%. The difference between Group 1 and -2 wards in period 2 was statistically significant (Fisher’s exact test, p < 0.0001). By week 70, when both interventions had been introduced to all six wards, the average percentage for each group of wards was in excess of 90% (Group 1, 91.4%; Group 2, 90.9%) (Fisher’s exact test, p = 0.205).
4. Discussion An understanding of the importance of respiratory rate monitoring is only now becoming apparent to those working outside critical care areas. This is perhaps not surprising, as its importance has generally not been stressed during undergraduate medical and nursing training, and few textbooks of patient assessment mention it [18]. Abnormal respiratory rate is a component of disordered physiology in many diseases of the cardiovascular, respiratory and renal systems, and is related to adverse outcomes [2–4,19–21], yet it has been the poor relation of monitoring. This has perhaps been compounded by the fact that most other vital signs can now be measured automatically on wards (e.g. pulse, blood pressure, temperature, peripheral O2 saturation), yet there is currently no automated respiratory rate monitor. The baseline data in our study demonstrate the low frequency of respiratory rate recording in the general wards of our hospital almost 2 years ago, and confirm the findings of other authors that respiratory rate is often under-recorded [5–10]. The introduction of a new vital signs chart to our wards produced a marked increase (38.6%) in respiratory recording within a few weeks on three wards (Group 2), even though MEWS was not also introduced there at the same
43
time. In those wards on which both a new chart and MEWS were introduced (Group 1), there was a greater improvement in respiratory rate recording over baseline figures (100%). After almost 70 months, the average percentage of occupied beds in which at least one respiratory rate recording had been made was over 90%, demonstrating a sustained, long-term effect. The reason for the beneficial effect of the introducing a new vital signs chart without MEWS is not clear. It may be due to nurses’ interest levels being raised by the accompanying educational sessions, or simply the effect of a new development. It is also possible that the improved respiratory rate recording on those wards with only a new chart might be the impact of other local initiatives in place throughout the hospital, e.g. the ALERT course [22] or nursing outreach team. However, both of these were established over 2 years prior to this study and their availability is evenly distributed throughout the hospital wards. Finally, a possible contamination effect, caused by ‘spill over’ of the impact of introducing MEWS to Group 1 wards is a possibility. Medical staff visiting Group 1 wards may have been influenced by MEWS and may have asked nurses on Group 2 wards to undertake respiratory rate monitoring. The baseline level of respiratory rate monitoring on Group 2 wards was higher than for Group 1 wards. The reason for this is unclear, but could have been simply due to a single nurse in a Group 2 ward being enthusiastic about respiratory rate monitoring. Irrespective of this baseline difference, there was a significant increase in Group 1 recording rate in audit period 2 and a marked improvement in respiratory rate has been demonstrated over a long period on all wards in this study. However, is important to appreciate that this study only measured the percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h. We have no data about the use of repeated respiratory rate recording in the 24-h period.
5. Conclusion This study confirms the beneficial effect of introducing the MEWS system to wards in our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This study has not investigated whether there has been a change in the quality of care of patients, which should be the focus for future research.
Acknowledgement The authors wish to acknowledge the assistance of Ms. Anne Spencer, Nursing and Midwifery Informatician, Portsmouth Hospitals Trust, who helped with the development of the database and with some of the data analyses.
44
J. McBride et al. / Resuscitation 65 (2005) 41–44
References [1] American College of Chest Physicians. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Society of Critical Care Medicine Consensus Conference. Crit Care Med 1992;20:864–74. [2] Fieselmann JF, Hendryx MS, Helms CM, Wakefield DS. Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients. J Gen Intern Med 1993;8:354–60. [3] Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125–31. [4] Durbin CG, Kopel RF. A case-control study of patients readmitted to the intensive care unit. Crit Care Med 1993;21:1547– 53. [5] Kenward G, Hodgetts T, Castle N. Time to put the R back in TPR. Nurs Times 2001;97:32–3. [6] Chellel A, Fraser J, Fender V, et al. Nursing observations on ward patients at risk of critical illness. Nurs Times 2002;98:36– 9. [7] Edwards SM, Murdin L. Respiratory rate – an under-documented clinical assessment. Clin Med 2001;1:85. [8] Helliwell VC, Hadfield JH, Gould T. Documentation of respiratory rate for acutely sick hospital in-patients – an observational study. Intensive Care Med 2002;28:21. [9] Rechner IJ, Odell M, Forster AL, et al. The use of MEWS as an outreach tool to identify hospital patients requiring critical care. Intensive Care Med 2002;28:21. [10] Hudson A. Prevention of in hospital cardiac arrests – first steps in improving patient care. Resuscitation 2004;60:113–5. [11] Odell M, Forster A, Rudman K, Bass F. The critical care outreach service and the early warning system on surgical wards. Nurs Crit Care 2002;7:132–5.
[12] Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997;8:100. [13] Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a surgical ward. Br J Anaesth 2000;84:663P. [14] Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 1999;54:853–60. [15] Subbe CP, Hibbs R, Williams E, Rutherford P, Gemmel L. ASSIST: a screening tool for the critically ill patients on general medical wards. Intensive Care Med 2002;28:21. [16] Houihan F, Bishop G, Hillman K, Daffurn K, Lee A. The Medical Emergency Team: a new strategy to identify and intervene in highrisk patients. Clin Intensive Care 1995;6:269–72. [17] Critical Care Outreach 2003. London: NHS Modernisation Agency; 2003. [18] Cook CJ, Smith GB. Do textbooks of clinical examination contain information regarding the assessment of critically ill patients? Resuscitation 2004;60:129–36. [19] Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult inpatients. Br J Anaesth 2004;92:882–4. [20] Buist M, Bernard S, Nguyen TV, More G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004;62:137–41. [21] Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardiopulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia 2003;58:775–803. [22] Smith GB, Osgood VM, Crane S. ALERTTM – a multiprofessional training course in the care of the acutely ill adult patient. Resuscitation 2002;52:281–6.
Long-term effect of introducing an early warning score on respiratory rate charting on general wards夽 Jackie McBride, Debbie Knight, Jo Piper, Gary B Smith∗ Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK Received 29 September 2004; accepted 23 October 2004
Abstract The respiratory rate is an early indicator of disease, yet many clinicians underestimate its importance and hospitals report a poor level of respiratory rate recording. We studied the short- and long-term effects of introducing a new patient vital signs chart and the modified early warning score (MEWS), which incorporates respiratory rate on the prevalence of respiratory rate recording in six general wards of our hospital. Prior to the commencement of the study, the average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5 ± 13.5%. After the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to three wards, this rose to 68.9 ± 20.9%. When all six wards had been using both the new chart and the MEWS system for almost 1 year, the figure had reached 91.2 ± 5.6%. During the pre-introduction period, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%; p = 0.118). During the second two audit periods, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (p < 0.001). The study confirms the long-term beneficial effect of introducing the MEWS system on respiratory rate recording into the general wards of our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This may have an impact on the future incidence of potentially avoidable cardiac arrest, deaths and unanticipated intensive care unit admission. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Breathing; Monitoring; Prevention; Respiration
1. Introduction The recording of a patient’s respiratory rate should be a routine component of clinical monitoring, as the respiratory rate is altered by numerous clinical states. These include shock, pain, cardiac failure, asthma, respiratory infection, drug administration and intoxication, cerebrovascular accidents, renal failure and diabetic ketoacidosis. The respiratory rate is also a component of the systemic inflammatory response syndrome (SIRS) [1], and is an important predictor of cardiopulmonary arrest [2,3] and readmission to a critical care unit [4]. Despite this, many clin夽 A Spanish and Portuguese translated version of the Abstract and Key-
words of this article appears at 10.1016/j.resuscitation.2004.10.015. ∗ Corresponding author. Tel.: +44 23 92286844; fax: +44 23 92286967. E-mail address: [email protected] (G.B. Smith). 0300-9572/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2004.10.015
icians underestimate the importance and usefulness of respiratory rate monitoring and recent reports demonstrate a poor level of respiratory rate recording in general hospital wards [5–10]. A range of early warning systems, which include the routine measurement of respiratory rate as a component, have been introduced in recent years to assist in the early detection of patient deterioration [11–17]. It might be anticipated that the introduction of such a scoring system would have an influence on the prevalence and frequency of respiratory rate recording. We have studied the effect of introducing a new patient vital signs chart and an early warning scoring system – the modified early warning score (MEWS) [13] – to a group of general wards in our hospital and have monitored their shortand long-term effects on the prevalence of respiratory rate recording.
42
J. McBride et al. / Resuscitation 65 (2005) 41–44
2. Method
3. Results
In September 2002, we introduced a new vital signs chart and the MEWS system to wards in our hospitals. To provide an indicator of their impact, we audited the prevalence of respiratory rate monitoring in the periods before and after their introduction. Baseline respiratory rate auditing commenced 17 weeks before the charts and MEWS was introduced (audit period 1); the baseline audit was continued for 5 weeks. Data were obtained from six general wards — two orthopaedic (A and D), two surgical (B and E) and two medical (C and F). On each day of the audit period, each ward was visited by one of the authors at approximately the same time each day. On each ward, the vital sign charts of the patients in 10 beds were scrutinised for evidence that at least one respiratory rate recording had been made in the prior 24 h. On each day, the beds chosen for audit were identical on each ward, but were varied on a daily basis. Beds that were empty at the time of audit were noted, but excluded from the final data analysis. The number of occupied beds, and the number of patients with at least one respiratory rate recording in the prior 24 h, were recorded for each ward on a daily basis and the totals summed for the whole audit period. The percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h was then calculated for each ward. On week 17 of the study, a new vital signs chart was introduced to all six wards. Each chart included a MEWS table and a section in which modified early warning scores could be documented. Nursing staff working on wards A, B and C were trained in the use of MEWS and the new vital signs chart during formal and informal training sessions lasting up to an hour. Members of staff on wards D, E and F were trained to use the new chart, but were instructed to disregard the MEWS system. Doctors were informed that not all wards would be capable of providing a MEWS. There was no overt transfer of nursing staff between wards during the study period. For the purpose of analysis, those wards where the vital signs chart and the MEWS system were both introduced at the start (A, B and C) were designated Group 1. Wards D, E and F, where the introduction of the new vital signs chart was the only initial intervention, were designated Group 2. Six weeks (week 23) after the introduction of the charts, the prevalence of respiratory rate monitoring on all wards was re-audited (audit period 2); the audit lasted for 7 weeks. From week 37, for approximately 4 weeks, nursing staff on wards D, E and F were trained in the use of MEWS. In week 67, 68 and 69, the prevalence of respiratory rate recording was again audited (audit period 3). Differences in respiratory rate prevalence between different time periods were compared using chi-squared (χ2 ) tests and Fisher’s exact test.
In audit period 1, prior to the introduction of the new vital signs chart and MEWS system, the total number of occupied beds in the six wards was 1251. The average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5 ± 13.5%. In audit period 2, i.e., after the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to wards A, B and C, the total number of occupied beds in the six wards was 1234; the average percentage where at least one respiratory rate recording had been made rose to 68.9 ± 20.9%. In audit period 3, when all six wards were using both the new chart and the MEWS system, the total number of occupied beds was 600 and the average percentage where at least one respiratory rate recording had been made reached 91.2 ± 5.6%. There was a statistically significant increase in the prevalence of respiratory rate recording between audit periods 1 and 3 (Fisher’s exact test, p < 0.0001). Table 1 shows the individual ward data for each audit period. The data show a clear rise in the percentage of occupied beds where at least one respiratory rate recording had been made for each ward during the study period. Fig. 1 demonstrates the data for each specialty group. During audit period 1, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%) (chi-squared (χ2 ), p = 0.118). During audit periods 2 and 3, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (chi-squared (χ2 ), p < 0.001). Table 1 The percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for each ward Ward
Audit period 1
2
3
A B C D E F
15.0 25.5 14.7 36.4 37.1 48.5
71.6 85.3 87.2 49.0 37.4 82.8
86.1 89.1 99.0 92.0 84.7 96.0
Fig. 1. Trend in percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for three different specialties.
J. McBride et al. / Resuscitation 65 (2005) 41–44
Fig. 2. Trend in percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h for Groups 1 and 2.
Fig. 2 shows the independent effect of introducing the new vital signs chart and MEWS. At baseline (audit period 1), there was a significant difference (Fisher’s exact test, p < 0.0001) between the two groups of wards (Group 1, 18.4%; Group 2, 40.7%). In the second audit period, i.e., after the introduction of the new vital signs chart to all six wards, the average percentage of occupied beds in which at least one respiratory rate recording had been made was 56.4% for Group 2 wards. However, the average percentage for those in which MEWS had also been introduced (Group 1) had risen to 81.4%. The difference between Group 1 and -2 wards in period 2 was statistically significant (Fisher’s exact test, p < 0.0001). By week 70, when both interventions had been introduced to all six wards, the average percentage for each group of wards was in excess of 90% (Group 1, 91.4%; Group 2, 90.9%) (Fisher’s exact test, p = 0.205).
4. Discussion An understanding of the importance of respiratory rate monitoring is only now becoming apparent to those working outside critical care areas. This is perhaps not surprising, as its importance has generally not been stressed during undergraduate medical and nursing training, and few textbooks of patient assessment mention it [18]. Abnormal respiratory rate is a component of disordered physiology in many diseases of the cardiovascular, respiratory and renal systems, and is related to adverse outcomes [2–4,19–21], yet it has been the poor relation of monitoring. This has perhaps been compounded by the fact that most other vital signs can now be measured automatically on wards (e.g. pulse, blood pressure, temperature, peripheral O2 saturation), yet there is currently no automated respiratory rate monitor. The baseline data in our study demonstrate the low frequency of respiratory rate recording in the general wards of our hospital almost 2 years ago, and confirm the findings of other authors that respiratory rate is often under-recorded [5–10]. The introduction of a new vital signs chart to our wards produced a marked increase (38.6%) in respiratory recording within a few weeks on three wards (Group 2), even though MEWS was not also introduced there at the same
43
time. In those wards on which both a new chart and MEWS were introduced (Group 1), there was a greater improvement in respiratory rate recording over baseline figures (100%). After almost 70 months, the average percentage of occupied beds in which at least one respiratory rate recording had been made was over 90%, demonstrating a sustained, long-term effect. The reason for the beneficial effect of the introducing a new vital signs chart without MEWS is not clear. It may be due to nurses’ interest levels being raised by the accompanying educational sessions, or simply the effect of a new development. It is also possible that the improved respiratory rate recording on those wards with only a new chart might be the impact of other local initiatives in place throughout the hospital, e.g. the ALERT course [22] or nursing outreach team. However, both of these were established over 2 years prior to this study and their availability is evenly distributed throughout the hospital wards. Finally, a possible contamination effect, caused by ‘spill over’ of the impact of introducing MEWS to Group 1 wards is a possibility. Medical staff visiting Group 1 wards may have been influenced by MEWS and may have asked nurses on Group 2 wards to undertake respiratory rate monitoring. The baseline level of respiratory rate monitoring on Group 2 wards was higher than for Group 1 wards. The reason for this is unclear, but could have been simply due to a single nurse in a Group 2 ward being enthusiastic about respiratory rate monitoring. Irrespective of this baseline difference, there was a significant increase in Group 1 recording rate in audit period 2 and a marked improvement in respiratory rate has been demonstrated over a long period on all wards in this study. However, is important to appreciate that this study only measured the percentage of occupied beds in which at least one respiratory rate recording had been made in the prior 24 h. We have no data about the use of repeated respiratory rate recording in the 24-h period.
5. Conclusion This study confirms the beneficial effect of introducing the MEWS system to wards in our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This study has not investigated whether there has been a change in the quality of care of patients, which should be the focus for future research.
Acknowledgement The authors wish to acknowledge the assistance of Ms. Anne Spencer, Nursing and Midwifery Informatician, Portsmouth Hospitals Trust, who helped with the development of the database and with some of the data analyses.
44
J. McBride et al. / Resuscitation 65 (2005) 41–44
References [1] American College of Chest Physicians. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Society of Critical Care Medicine Consensus Conference. Crit Care Med 1992;20:864–74. [2] Fieselmann JF, Hendryx MS, Helms CM, Wakefield DS. Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients. J Gen Intern Med 1993;8:354–60. [3] Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125–31. [4] Durbin CG, Kopel RF. A case-control study of patients readmitted to the intensive care unit. Crit Care Med 1993;21:1547– 53. [5] Kenward G, Hodgetts T, Castle N. Time to put the R back in TPR. Nurs Times 2001;97:32–3. [6] Chellel A, Fraser J, Fender V, et al. Nursing observations on ward patients at risk of critical illness. Nurs Times 2002;98:36– 9. [7] Edwards SM, Murdin L. Respiratory rate – an under-documented clinical assessment. Clin Med 2001;1:85. [8] Helliwell VC, Hadfield JH, Gould T. Documentation of respiratory rate for acutely sick hospital in-patients – an observational study. Intensive Care Med 2002;28:21. [9] Rechner IJ, Odell M, Forster AL, et al. The use of MEWS as an outreach tool to identify hospital patients requiring critical care. Intensive Care Med 2002;28:21. [10] Hudson A. Prevention of in hospital cardiac arrests – first steps in improving patient care. Resuscitation 2004;60:113–5. [11] Odell M, Forster A, Rudman K, Bass F. The critical care outreach service and the early warning system on surgical wards. Nurs Crit Care 2002;7:132–5.
[12] Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997;8:100. [13] Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a surgical ward. Br J Anaesth 2000;84:663P. [14] Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 1999;54:853–60. [15] Subbe CP, Hibbs R, Williams E, Rutherford P, Gemmel L. ASSIST: a screening tool for the critically ill patients on general medical wards. Intensive Care Med 2002;28:21. [16] Houihan F, Bishop G, Hillman K, Daffurn K, Lee A. The Medical Emergency Team: a new strategy to identify and intervene in highrisk patients. Clin Intensive Care 1995;6:269–72. [17] Critical Care Outreach 2003. London: NHS Modernisation Agency; 2003. [18] Cook CJ, Smith GB. Do textbooks of clinical examination contain information regarding the assessment of critically ill patients? Resuscitation 2004;60:129–36. [19] Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores are related to mortality in adult inpatients. Br J Anaesth 2004;92:882–4. [20] Buist M, Bernard S, Nguyen TV, More G, Anderson J. Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004;62:137–41. [21] Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardiopulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia 2003;58:775–803. [22] Smith GB, Osgood VM, Crane S. ALERTTM – a multiprofessional training course in the care of the acutely ill adult patient. Resuscitation 2002;52:281–6.