Early Warning Scorecard Helps Identify Signs of Patient Deterioration in Oncology

Using a color-coded, pocket-sized early warning scorecard has the potential to help nurses and other clinicians assess when cancer patients are deteriorating, and it's an intervention that could help avoid acute hospitalizations and even save lives, according to two clinical nurse specialists from Johns Hopkins who shared their experience with piloting an early warning tool.

Mikaela Olsen, RN, MS, AOCNS

Using a color-coded, pocket-sized early warning scorecard has the potential to help nurses and other clinicians assess when cancer patients are deteriorating, and it’s an intervention that could help avoid acute hospitalizations and even save lives, according to two clinical nurse specialists from Johns Hopkins who shared their experience with piloting an early warning tool.

The decision to explore the utility of an early warning scoring system at Johns Hopkins followed the unexpected death of a young oncology patient, prompting the nursing staff to find meaning in that experience, explained presenters Mikaela Olsen, RN, MS, AOCNS, and Kathy Mooney, RN, OCN, BMTCN, at the 40th Annual ONS Congress.

Developed by researchers in the United Kingdom in 1997, early warning systems (EWS) are designed to identify patients who are at risk for clinical deterioration. Modified versions (MEWS) have been introduced over the years, but use of the systems in oncology practice has been limited, noted Mooney. This is despite evidence that having objective criteria increases reassessment of abnormal patient parameters, along with boosting nurses’ decision making confidence.

And, such objective assessment is particularly helpful to recent nursing graduates, who early in their careers may not be as intuitively aware of what they should be watching out for.

“We really wanted to get away from the nurse calling the physician … and just saying, ‘I don’t feel right—you have to come see this patient,’” said Olsen.

Their quality improvement project began with an oncology-focused literature review of EWS use, which showed that approximately 80% of in-hospital cardiac arrests are usually preceded by physiologic instability in one or more vital signs.

The research team then surveyed nurses before piloting the tool in two inpatient hematology/oncology units and two ambulatory oncology clinics, including a phlebotomy provider area staffed by 15 clinical technicians and one RN. Olsen said that EWS can be especially helpful in settings where blood is drawn and vital signs are taken by non-nursing staff, providing these clinicians with objective guidance for when to alert nurses that a patient is deteriorating and may need to be rerouted.

This pre-intervention survey found that 92% of nurses felt “somewhat to very” confident in their ability to detect changes in patients that could indicate deterioration; that reassessment frequency varied widely; and that most of the RNs felt that objective validated criteria to identify deteriorating patients would improve reassessment frequency, communication, and patient safety.

When asked which signs are most indicative of clinical deterioration, respondents to the pre-intervention survey listed pulse, blood pressure, and change in level of consciousness.

The nurses said that they wanted to keep the intervention simple and thus opted for a modified traffic light color coding system, using green, yellow, orange, and red. On the front of the scorecard, clinicians can see the parameters for temperature, pulse rate, systolic BP, respiratory rate (breaths per minute), urine output, and alertness; on the back, it lists reassessment frequency parameters based on the color where the patient has scored.

“I really think the beauty of this is that the clin tech can report abnormal measurements to the nurse, but they don’t have to ask the nurse when they should go back and get another set of items,” noted Olsen.

In a post-intervention survey after using the tool, Olsen said that all of the respondents now felt somewhat to very confident in their ability to detect changes in patients that could indicate deterioration. The investigators did see a change in the parameters the respondents thought were indicative of deterioration—now including respiratory rate.

Reassessment frequency still varied even with the tool, according to post-intervention survey responses, and time was a problem both before and after the intervention, with nurses reporting that busy assignments continue to interfere with their ability to detect deteriorating patients.

The researchers concluded that “the use of an early warning system is important in the prediction of clinical deterioration in patients and recommended by the Institute for Healthcare’s 5 Million Lives Campaign.”

Even so, they stressed that the scorecard should not be viewed as “the ‘be-all’ and ‘end-all.’” To be effective, “it must be combined with critical clinical judgment.”

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