Catching the early moments when a patient’s vitals deteriorate can mean life or death for the patient. That’s why it’s critical to find ways to monitor those vitals in near real time. One nonprofit hospital in Egypt established an early warning system within its Cerner electronic medical record (EMR) to help keep inpatients’ health from quickly deteriorating.
Children’s Cancer Hospital Egypt (CCHE), widely known as Hospital 57357, is one of the largest specialized children’s cancer hospital in the world in terms of capacity, with 320 beds available.1 It was established in 2007 with the mission of providing the best comprehensive, pediatric-centered quality of care, free of charge and without discrimination.
In 2018, CCHE leadership looked for ways to decrease the number of inpatients from entering code blue or code yellow scenarios. CCHE defines code yellow as a call for urgent Intensive Care Unit (ICU) consultation in less than five minutes upon recognition of signs of a patient’s deterioration. CCHE defines code blue as a call for basic life support immediately upon recognition of cardiac or respiratory arrest, where advanced life support is implemented in less than two minutes.
“Early intervention is critical to help prevent negative health outcomes,” said Mohamed Aggag, MD, chief medical officer and chief medical informatics officer. “We wanted to set up a clear way to quantify what was causing some pediatric patients’ health conditions to deteriorate and be able to respond to those deteriorations quickly.”
With the help of Cerner solutions, the CCHE team created a Pediatric Early Warning Score (PEWS). PEWS automation alerts nursing staff to a patient’s deteriorating condition and helps providers recognize and alarm against health events such as changes in respiratory rate, oxygen saturation, and other cardiac and neurological issues. PEWS is based on the assessment of a patient’s vital signs from configured clinical documentation in the EMR. Each vital sign is valued according to its variance from normal to produce an overall score. A high score indicates a risk of critical illness, and PEWS fires an alert that prompts clinicians to complete an escalating series of actions to help the inpatient.
“PEWS leverages existing functionality and fits seamlessly into the clinician’s workflows,” said Laila Ezzat, nursing informatics team leader. “There are multiple alerts that can be fired depending on the PEWS score, and the specific rule that fires quickly takes the clinician to the next step in order to help the clinician in efforts to improve the patient’s condition.”
The PEWS project began in 2018 with planning and gathering feedback from clinicians about what could be measured, and then data was collected to design an embedded form in the Cerner EMR. The next step was staff training and briefing sessions with monitoring and reporting established to ensure compliance. Then the CCHE project team gathered feedback from users to identify and address gaps in the PEWS design. To help maintain compliance, they developed robust reporting and encouraged staff to provide feedback on every step of the workflow.
“For PEWS to work effectively, we worked cooperatively with multiple departments, including the quality, physicians, nursing, and medical and nursing informatics teams, and incorporated their suggestions,” said Mohamed Mostafa, nursing informatics.
Following implementation, CCHE saw improvement in the number of code blue and code yellow cases. Code blue cases fell 28%, and code yellow cases fell 44%.2 PEWS also provided information to clinicians to help them make informed decisions about when to transfer patients to the ICU. The percentage of cases accurately transferred to the ICU improved from 50% to 92%.3
“Without Cerner’s EMR, we wouldn’t have been able to create the needed documentation and we wouldn’t be alerted when an inpatient’s PEWS score increased,” said Dina Alaa, MBA, medical informatics team leader. “The configured clinical documentation in the EMR played a major role in helping to assess the PEWS score.”
Going forward, CCHE continues to fine tune PEWS with the goal of increasing its effectiveness and accuracy.
2 Comparing the number of code blue and code yellow cases from May-November 2019 to May-November 2020.
3 Comparing the number ICU cases from March 2020 to December 2020 that were sent to the ICU and met the specific PEWS score requiring ICU care. Excludes ICU cases involving post-operative, tumor lysis, convulsions, pulmonary hemorrhage, hypotension, chest tubes, electrolyte imbalance, MTX toxicity, and cases following a code yellow (not related to score) or code blue alert or a lower PEWS score.