American College of Physicians: Internal Medicine — Doctors for Adults ®


System catches codes before they’re called

From the March ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Susan FitzGerald

Where: Mercy Hospital Anderson, a 218-bed, acute-care facility in Cincinnati, Ohio.

The issue: Reducing the number of code blues called outside the ICU and improving hospital mortality rates.


As part of a quality improvement effort to reduce mortality rates, clinicians at Mercy Hospital Anderson instituted a review of patient charts in which a code blue was called. They found some cases in which it appeared earlier action might have prevented a patient from arresting.

“We were seeing nursing documentation of restlessness, multiple calls to adjust medications, and things like that hours before the code occurred, but there was not a real significant decline in one vital sign,” said Janice Maupin, RN, Mercy’s director of quality and case management.

Ms. Maupin had heard from a colleague at another hospital about the Modified Early Warning System (MEWS), a scoring system that identifies high-risk patients using vital signs. She and other hospital leaders retrospectively applied MEWS scoring to code blues called on Mercy’s medical/surgical/telemetry unit in 2007. They calculated that, had MEWS scoring been in place at that time, 60% of the code blues could have been prevented and patients’ deterioration could have been identified 6.6 hours earlier, on average. They began a pilot of MEWS in the medical/surgical/oncology unit in early 2008 and the program went hospital-wide later that year.

How it works

At the start of each 12-hour shift, or more often if indicated, patients are assigned a MEWS score based on five vital signs: heart rate, blood pressure, respiratory rate, temperature and level of consciousness. A nurse logs the vital sign data into the electronic medical chart and a number ranging from 0-3 is assigned to each of the parameters.

The nurse then calculates a total MEWS score that corresponds to a set response ranging from “Continue routine/ordered monitoring” to “Call RRT [rapid response team] and physician STAT. Recommended transfer to higher level of care. Is end-of-life discussion with patient/family indicated?”

A hospital-wide report on MEWS scores is generated twice a day, and patients with a score of at least 3 are seen by an advanced practice nurse.

The challenge

Ms. Maupin and her staff had to convince physicians and nurses of the system’s value: “Some saw the benefit right away; others had to be convinced it would not take up a lot of their time.”


The hospital has reduced code blues outside the ICU by over 50% and increased rapid response team calls by over 100%. Code blues decreased from 28 between August 2007 and July 2009 to 14 from August 2008 to July 2009. Stephen R. Feagins, FACP, a hospitalist and Mercy Hospital Anderson’s vice president for medical affairs, said MEWS has enhanced communication between nurses and doctors. “It can be frustrating to some doctors to get a call saying that the patient is sicker,” Dr. Feagins said. “This provides a quantifiable way to describe a patient: ‘He went from a 2 to a 5’.” The system also gives nurses more confidence when they call a doctor, Ms. Maupin said.

Lessons learned

MEWS scoring must fit naturally into the staff’s routine. “It can’t be an additional form or any additional step. It has to seem like it’s a normal part of their daily workload,” Ms. Maupin said. “We worked with our IT department to build the scoring system into the screen where a nurse usually documents vital signs.”

There has to be a protocol for responding to elevated MEWS scores, and the staff need regular feedback on how well the system is working so they are reminded of its benefits, she added. Right now, MEWS is used at Mercy about 85% of the time.

How patients benefit

Earlier identification of a patient’s subtle signs of deterioration helps avoid the chaos of a code blue call, and may save lives. The hospital’s mortality rate went from 1.7% to 1.4% hospital-wide after MEWS was implemented.

Next step

The hospital recently added a new MEWS component that requires patients to be assigned a score when they are about to be transferred, then reevaluated within 30 minutes after getting to the new unit.

Susan FitzGerald is a freelance writer based in Philadelphia.


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