Authors (including presenting author) :
KF Wong(1), Jeffery Lai(1), Macro Chan(1), Carmen Lam(1), Benny Cheng(1), Gladys Kwan(1), PF Tang(1), SK Leung(2), Carmen Yu(2), WL Yu(2), CK Wo(2), CM Chung(2), Salina Lo(2), Simon Y. W. Li(3), Calvin Or(4)
Affiliation :
(1) CARES program workgroup, NTWC
(2) Department of Surgery, NTWC
(3) School of Psychological Science, The University of Western Australia
(4) Department of Industrial & Manufacturing Systems Engineering, The University of Hong Kong
Introduction :
Sudden patient deterioration/ unexpected mortality (8.9% in an internal NTWC surgical departmental review) is not uncommon in clinical practice.
Early warning score is designed to provide early indication of patients’ deterioration, however, it is not widely adopted in Hong Kong clinical practice because of a number of factors: concerns of heavy workload on clinicians and healthcare workers, difficulty in measuring vital signs such as respiratory rate, etc.
Objectives :
To address the low adoption rate of early warning score systems, Critical Actions for Response and Escalation System, CARES, is designed to provide a user friendly, evidence-based and protocol-driven electronic system for patients’ monitoring and management.
Methodology :
CARES consists of three major components: (1) electronic early warning score (e-EWS) system, (2) National Early Warning Score-2 (NEWS-2), which was formulated by the Royal College of Physicians of the United Kingdom, and has an area under ROC curve of 0.85 in predicting mortality and ICU admission, and (3) protocol-driven, follow-up clinical actions for patients care.
By using the e-EWS system, clinical parameters, including machine measured respiratory rate (RR), SpO2, body temperature, heart rate (HR), systolic blood pressure (SBP), level of consciousness, requirement of using O2, will automatically be recorded and sent to a central display monitor and e-chart devices (I-pad). This, in turn, has the benefit of reducing frontline staffs’ manual work and minimizing data entry errors, data omission, and data loss.
NEWS-2 score, with a better correlation than the modified early warning score (MEWS) to detect patients’ deterioration, will then be calculated by a pre-determined algorithm; alarms will go off when patients are at risk.
A protocol driven action plan will indicate to clinicians according to patient’s corresponding risk score (low, intermediate or high risk). Timely management can then be devised to minimize any treatment delay.
After setting up of the e-EWS system, fixing its software bugs, completed staff training and familiarization of the program, CARES was implemented in a surgical ward in Tuen Mun Hospital.
Result & Outcome :
Completeness of vital signs, those necessary for early warning score, including RR (99.77% vs 25.87%), temperature (99.98% vs 34.3%), level of consciousness (99.7% vs 24.41%), early warning score calculation (99.69% vs 24.26%) and accuracy of score (100% vs 95.7%) were significantly higher (p < 0.001) after the implementation of CARES program.
Regarding staff acceptance, questionnaire surveys were conducted to measure acceptance at different timepoints (before the implementation of the CARES program and 3 months and 6 months after the implementation), which showed that the program is well accepted and credited by healthcare workers. 83.3% and 88.9% involved nursing staffs considered the program improved patients care/ management and found this useful for patients care respectively.
Conclusion:
The implementation of CARES, coupled with an e-EWS, result in an increase in completeness of vital sign documentation in our surgical ward. Moreover, the system was accepted and positively evaluated by the ward staff. Although clinical effectiveness of CARES needs further and more elaborate evaluations, the current study represents a first step to show its potential.
