Early Warning/Track-and-Trigger Systems to Detect Deterioration and Improve Outcomes in Hospitalized Patients

Ariel L. Shiloh; George Lominadze; Michelle N. Gong; Richard H. Savel

doi:10.1055/s-0035-1570352

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2016; 37(01): 088-095
DOI: 10.1055/s-0035-1570352

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Early Warning/Track-and-Trigger Systems to Detect Deterioration and Improve Outcomes in Hospitalized Patients

Ariel L. Shiloh

¹Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, New York

,

George Lominadze

¹Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, New York

,

Michelle N. Gong

¹Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, New York

,

Richard H. Savel

²Section of Surgical Critical Care, Albert Einstein College of Medicine, Maimonides Medical Center, New York, New York

› Author Affiliations

Abstract

As a global effort toward improving patient safety, a specific area of focus has been the early recognition and rapid intervention in deteriorating ward patients. This focus on “failure to rescue” has led to the construction of early warning/track-and-trigger systems. In this review article, we present a description of the data behind the creation and implementation of such systems, including multiple algorithms and strategies for deployment. Additionally, the strengths and weaknesses of the various systems and their evaluation in the literature are emphasized. Despite the limitations of the current literature, the potential benefit of these early warning/track-and-trigger systems to improve patient outcomes remains significant.

Keywords

early warning/track-and-trigger systems - patient safety - patient deterioration - early detection - early response

Full Text

References

References
1 Hillman KM, Bristow PJ, Chey T , et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med 2002; 28 (11) 1629-1634
2 Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 (2) 139-146
3 Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006; 295 (3) 324-327
4 Jansen JO, Cuthbertson BH. Detecting critical illness outside the ICU: the role of track and trigger systems. Curr Opin Crit Care 2010; 16 (3) 184-190
5 Harrison GA, Jacques TC, Kilborn G, McLaws M-L. The prevalence of recordings of the signs of critical conditions and emergency responses in hospital wards—the SOCCER study. Resuscitation 2005; 65 (2) 149-157
6 Lee A, Bishop G, Hillman KM, Daffurn K. The medical emergency team. Anaesth Intensive Care 1995; 23 (2) 183-186
7 Psirides A, Hill J, Hurford S. A review of rapid response team activation parameters in New Zealand hospitals. Resuscitation 2013; 84 (8) 1040-1044
8 Jones D, Duke G, Green J , et al. Medical emergency team syndromes and an approach to their management. Crit Care 2006; 10 (1) R30
9 Cuthbertson BH, Smith GB. A warning on early-warning scores!. Br J Anaesth 2007; 98 (6) 704-706
10 Smith GB, Prytherch DR, Schmidt PE, Featherstone PI, Higgins B. A review, and performance evaluation, of single-parameter “track and trigger” systems. Resuscitation 2008; 79 (1) 11-21
11 Bellomo R, Goldsmith D, Uchino S , et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 2004; 32 (4) 916-921
12 Bellomo R, Goldsmith D, Uchino S , et al. A prospective before-and-after trial of a medical emergency team. Med J Aust 2003; 179 (6) 283-287
13 Jones D, Bellomo R, Bates S , et al. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care 2005; 9 (6) R808-R815
14 Hillman K, Chen J, Cretikos M , et al; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365 (9477) 2091-2097
15 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 (9) 853-860
16 Bleyer AJ, Vidya S, Russell GB , et al. Longitudinal analysis of one million vital signs in patients in an academic medical center. Resuscitation 2011; 82 (11) 1387-1392
17 Allgöwer M, Burri C. [“Shock index”]. Dtsch Med Wochenschr 1967; 92 (43) 1947-1950
18 Keller AS, Kirkland LL, Rajasekaran SY, Cha S, Rady MY, Huddleston JM. Unplanned transfers to the intensive care unit: the role of the shock index. J Hosp Med 2010; 5 (8) 460-465
19 Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia 2003; 58 (8) 797-802
20 Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM 2001; 94 (10) 521-526
21 Morgan R, Williams F, Wright M. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997; 8 (2) 100
22 Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS—Towards a national early warning score for detecting adult inpatient deterioration. Resuscitation 2010; 81 (8) 932-937
23 National Early Warning Score (NEWS): Standardising the assessment of acute-illness severity in the NHS. Report of a Working Party. London: RCP; 2012
24 Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI. The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation 2013; 84 (4) 465-470
25 Subbe CP. Better ViEWS ahead? It is high time to improve patient safety by standardizing Early Warning Scores. Resuscitation 2010; 81 (8) 923-924
26 Jarvis S, Kovacs C, Briggs J , et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015; 87: 75-80
27 Mathukia C, Fan W, Vadyak K, Biege C, Krishnamurthy M. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Community Hosp Intern Med Perspect 2015; 5 (2) 26716
28 Harrison GA, Jacques T, McLaws ML, Kilborn G. Combinations of early signs of critical illness predict in-hospital death-the SOCCER study (signs of critical conditions and emergency responses). Resuscitation 2006; 71 (3) 327-334
29 Jacques T, Harrison GA, McLaws ML, Kilborn G. Signs of critical conditions and emergency responses (SOCCER): a model for predicting adverse events in the inpatient setting. Resuscitation 2006; 69 (2) 175-183
30 Eccles SR, Subbe C, Hancock D, Thomson N. CREWS: improving specificity whilst maintaining sensitivity of the National Early Warning Score in patients with chronic hypoxaemia. Resuscitation 2014; 85 (1) 109-111
31 Escobar GJ, LaGuardia JC, Turk BJ, Ragins A, Kipnis P, Draper D. Early detection of impending physiologic deterioration among patients who are not in intensive care: development of predictive models using data from an automated electronic medical record. J Hosp Med 2012; 7 (5) 388-395
32 Churpek MM, Yuen TC, Edelson DP. Predicting clinical deterioration in the hospital: the impact of outcome selection. Resuscitation 2013; 84 (5) 564-568
33 Hands C, Reid E, Meredith P , et al. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf 2013; 22 (9) 719-726
34 Yiu CJ, Khan SU, Subbe CP, Tofeec K, Madge RA. Into the night: factors affecting response to abnormal Early Warning Scores out-of-hours and implications for service improvement. Acute Med 2014; 13 (2) 56-60
35 Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994; 22 (2) 244-247
36 The Joint Commission. National Patient safety goals for hospitals. Oak Brook, IL: Joint Commission Resources; 2009
37 Devita MA, Bellomo R, Hillman K , et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34 (9) 2463-2478
38 Litvak E, Pronovost PJ. Rethinking rapid response teams. JAMA 2010; 304 (12) 1375-1376
39 Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158 (5, Pt 2) 417-425
40 Black AD, Car J, Pagliari C , et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med 2011; 8 (1) e1000387
41 Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to national early warning score (NEWS). Resuscitation 2015; 90: 85-90
42 Smith AF, Oakey RJ. Incidence and significance of errors in a patient ‘track and trigger’ system during an epidemic of Legionnaires' disease: retrospective casenote analysis. Anaesthesia 2006; 61 (3) 222-228
43 Prytherch DR, Smith GB, Schmidt P , et al. Calculating early warning scores—a classroom comparison of pen and paper and hand-held computer methods. Resuscitation 2006; 70 (2) 173-178
44 Hillman KM, Bristow PJ, Chey T , et al. Antecedents to hospital deaths. Intern Med J 2001; 31 (6) 343-348
45 Hodgetts TJ, Kenward G, Vlackonikolis I , et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002; 54 (2) 115-123
46 Jones S, Mullally M, Ingleby S, Buist M, Bailey M, Eddleston JM. Bedside electronic capture of clinical observations and automated clinical alerts to improve compliance with an Early Warning Score protocol. Crit Care Resusc 2011; 13 (2) 83-88
47 Schmidt PE, Meredith P, Prytherch DR , et al. Impact of introducing an electronic physiological surveillance system on hospital mortality. BMJ Qual Saf 2015; 24 (1) 10-20
48 Kellett J. How much of NEWS could be measured by a machine, and would it work?. Resuscitation 2014; 85 (9) e147
49 Watkinson PJ, Barber VS, Price JD, Hann A, Tarassenko L, Young JD. A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. Anaesthesia 2006; 61 (11) 1031-1039
50 Liu Y, Zhu SH, Wang GH, Ye F, Li PZ. Validity and reliability of multiparameter physiological measurements recorded by the Equivital LifeMonitor during activities of various intensities. J Occup Environ Hyg 2013; 10 (2) 78-85
51 Bonnici T, Tarassenko L, Clifton DA, Watkinson P. The digital patient. Clin Med 2013; 13 (3) 252-257
52 Churpek MM, Yuen TC, Winslow C , et al. Multicenter development and validation of a risk stratification tool for ward patients. Am J Respir Crit Care Med 2014; 190 (6) 649-655
53 Finlay GD, Rothman MJ, Smith RA. Measuring the modified early warning score and the Rothman index: advantages of utilizing the electronic medical record in an early warning system. J Hosp Med 2014; 9 (2) 116-119
54 Kirkland LL, Malinchoc M, O'Byrne M , et al. A clinical deterioration prediction tool for internal medicine patients. Am J Med Qual 2013; 28 (2) 135-142