Using a Modified Early Warning System (mEWS) to Improve Antibiotic Administration in Cancer Patients With a Sepsis Diagnosis Charli Peters , RN, BSN In Partial Fulfillment of the Doctor of Nursing Practice Degree PURPOSE BACKGROUND BACKGROUND Acknowledgements: Content Experts Dr. Kencee Graves MD, Dr. Devin Horton MD, Dr. William Dunson MD, John Arego BSCS. Project Chair: Mary Vietti, DNP, APRN To determine whether a calculated mEWS score on admission vital signs quickened recognition of sepsis and thus decreased time to antibiotic administration in septic patients. • Sepsis is a systemic inflammatory response to infection that results in organ dysfunction and circulatory collapse. • Delayed recognition of the septic patient is associated with increased sepsis mortality, possibly due to delay of antibiotic administration. • Signs of early sepsis are subtle and easily overlooked. • In 2003 the Surviving Sepsis Campaign was published to raise awareness and recognition of the mortality and morbidity of sepsis and improved outcomes with early intervention. • The Surviving Sepsis Campiagn developed treatment bundles requiring antibiotic administration within 3 hours of presentation. • Improved sepsis recognition has been attributed to implementing and utilizing a disease severity scorecard such as the mEWS. • In mEWS a numerical value is assigned to each vital sign based on each parameter’s degree of deviation from normal; the sum determines the score and thus the degree of risk for sepsis: example below RESULTS 0 50 100 150 200 250 300 350 400 Total Septic mEWS >3 mEWS <3 Average Time to Antibiotics in Minutes Pre Post 4hrs 16 mins 3hrs 50 mins 3hrs 41 mins Met Bundle 67% Didn't Meet Bundle 33% All Sepsis Post-mEWS Compliance to ABX in 3 hrs Measure 3 2 1 0 1 2 3 Temperature <36.0 36.1-38.0 38.1-39.0 >39.1 Respiratory Rate <8 9-11 12-20 21-25 26-30 >31 Pulse <40 41-50 51-100 101-110 111-130 >131 Systolic BP <79 81-90 91-100 101-150 151-190 191-220 >221 METHODS • Retrospective chart analysis of two cohorts of patients evaluated in the urgent cancer care clinic over two different time periods: • Cohort #1: Pre-mEWS implementation January 1, 2015 to January 31, 2015. • Cohort #2: Post-mEWS implementation January 1, 2016 to January 31, 2016. • Demographic Data: age, gender, cancer diagnosis, visit diagnosis. • Study Specific Data: admit time, vital signs, and calculated mEWS score • Time of antibiotic order, and time to antibiotic administration. • Data analyzed for comparison of cohorts. mEWS Scoring: A 36 year old gentleman with osteosarcoma presented to the clinic with these vital signs: Temp 39.4, HR 133, BP 94/55, RR 28. This patients mEWS score was 9 at initial triage. • As of October 2015, CMS is requiring the use of the three hour treatment bundle to determine hospital reimbursement. • 46% of deaths from 1/1/14 to 9/15/15 had sepsis related diagnosis in the death record, at the cancer hospital studied for this project. • Cancer patients are particularly vulnerable to developing sepsis as they have treatment and disease associated immune impairment. • As a result, this study facility has implemented a sepsis initiative utilizing a mEWS score as defined by hospital wide administration consensus. They have determined a mEWS score of 3 as an initial score within this clinic to further evaluate for sepsis. OBJECTIVES • Coordinate with administration for appropriate mEWS criteria for study as approved by IRB. • Approval by IRB to move forward with data collection. • Coordinate with hospital clinical staff education to ensure mEWS processes in place prior to study initiation. • Collect retrospective data on urgent care clinic patients prior to mEWS roll out and post mEWS roll out. • Determine if a mEWS score improved time to antibiotic administration in cancer patients with a sepsis diagnosis. • Disseminate data to hospital administration and abroad to the University of Utah Evidence Base Practice Fair. • 199 patients were evaluated pre-mEWS, 14 patients had a sepsis diagnosis which comprised 7% of the population evaluated. • 189 patients post-mEWS were evaluated, 15 patients had a sepsis diagnosis which comprised 8% of the population evaluated. • mEWS improved time to antibiotic administration in post-mEWS cohort in all sepsis diagnoses by 2 hours 50mins on average. • The Pre-mEWS cohort only met the three hour goal to antbiotic administration 36% of the time, compared to the post mEWS cohort who met the surviving sepsis antibiotic guideline 67% of the time. Met Bundle 36% Didn't Meet Bundle 64% All Sepsis Pre-mEWS Compliance to ABX in 3hrs CONCLUSIONS/RECOMENDATIONS • While overall time to antibiotic administration was improved in the post mEWS cohort, due to the law of small numbers, longer data collection should be evaluated to capture true improvement with a larger sample. • To capture true compliance to the three hour sepsis bundle, other components in addition to antibiotics including lactate measurement, blood culture collection and administration of fluids for hypotension or lactic acidosis should be measured and evaluated. • Although we had an overall improvement, mEWS criteria may need to be altered to better capture the neutropenic cancer population, as these patients may be unable to mount the inflammatory response required to trigger mEWS as defined in the study. 5hrs 51 mins 3 hrs 2hrs 50 mns 3 hrs 1 min
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Using a Modified Early Warning System (mEWS) to Improve Antibiotic Administration in Cancer Patients With a Sepsis
Diagnosis Charli Peters , RN, BSN
In Partial Fulfillment of the Doctor of Nursing Practice Degree
PURPOSE
BACKGROUND
BACKGROUND
Acknowledgements: Content Experts Dr. Kencee Graves MD, Dr. Devin Horton MD, Dr. William Dunson MD, John Arego BSCS. Project Chair: Mary Vietti, DNP, APRN
To determine whether a calculated mEWS score on admission vital signs quickened recognition of sepsis and thus decreased time to antibiotic administration in septic patients.
• Sepsis is a systemic inflammatory response to infection that results in organ dysfunction and circulatory collapse.
• Delayed recognition of the septic patient is associated with increased sepsis mortality, possibly due to delay of antibiotic administration.
• Signs of early sepsis are subtle and easily overlooked. • In 2003 the Surviving Sepsis Campaign was published to raise
awareness and recognition of the mortality and morbidity of sepsis and improved outcomes with early intervention.
• The Surviving Sepsis Campiagn developed treatment bundles requiring antibiotic administration within 3 hours of presentation.
• Improved sepsis recognition has been attributed to implementing and utilizing a disease severity scorecard such as the mEWS.
• In mEWS a numerical value is assigned to each vital sign based on each parameter’s degree of deviation from normal; the sum determines the score and thus the degree of risk for sepsis: example below
RESULTS
0
50
100
150
200
250
300
350
400
Total Septic mEWS >3 mEWS <3
Average Time to Antibiotics in Minutes
Pre Post
4hrs 16 mins 3hrs
50 mins
3hrs 41 mins
Met Bundle
67%
Didn't Meet
Bundle 33%
All Sepsis Post-mEWS Compliance to ABX in 3 hrs
Measure 3 2 1 0 1 2 3
Temperature <36.0 36.1-38.0 38.1-39.0 >39.1
Respiratory Rate
<8 9-11 12-20 21-25 26-30 >31
Pulse <40 41-50 51-100 101-110 111-130 >131
Systolic BP <79 81-90 91-100 101-150 151-190 191-220 >221
METHODS
• Retrospective chart analysis of two cohorts of patients evaluated in the urgent cancer care clinic over two different time periods:
• Cohort #1: Pre-mEWS implementation January 1, 2015 to January 31, 2015.
• Cohort #2: Post-mEWS implementation January 1, 2016 to January 31, 2016.
• Demographic Data: age, gender, cancer diagnosis, visit diagnosis. • Study Specific Data: admit time, vital signs, and calculated mEWS
score • Time of antibiotic order, and time to antibiotic administration. • Data analyzed for comparison of cohorts.
mEWS Scoring: A 36 year old gentleman with osteosarcoma presented to the clinic with these vital signs: Temp 39.4, HR 133, BP 94/55, RR 28. This patients mEWS score was 9 at initial triage.
• As of October 2015, CMS is requiring the use of the three hour treatment bundle to determine hospital reimbursement.
• 46% of deaths from 1/1/14 to 9/15/15 had sepsis related diagnosis in the death record, at the cancer hospital studied for this project.
• Cancer patients are particularly vulnerable to developing sepsis as they have treatment and disease associated immune impairment.
• As a result, this study facility has implemented a sepsis initiative utilizing a mEWS score as defined by hospital wide administration consensus. They have determined a mEWS score of 3 as an initial score within this clinic to further evaluate for sepsis.
OBJECTIVES
• Coordinate with administration for appropriate mEWS criteria for study as approved by IRB.
• Approval by IRB to move forward with data collection. • Coordinate with hospital clinical staff education to ensure mEWS
processes in place prior to study initiation. • Collect retrospective data on urgent care clinic patients prior to mEWS roll
out and post mEWS roll out. • Determine if a mEWS score improved time to antibiotic administration in
cancer patients with a sepsis diagnosis. • Disseminate data to hospital administration and abroad to the University of
Utah Evidence Base Practice Fair.
• 199 patients were evaluated pre-mEWS, 14 patients had a sepsis diagnosis which comprised 7% of the population evaluated.
• 189 patients post-mEWS were evaluated, 15 patients had a sepsis diagnosis which comprised 8% of the population evaluated.
• mEWS improved time to antibiotic administration in post-mEWS cohort in all sepsis diagnoses by 2 hours 50mins on average.
• The Pre-mEWS cohort only met the three hour goal to antbiotic administration 36% of the time, compared to the post mEWS cohort who met the surviving sepsis antibiotic guideline 67% of the time.
Met Bundle
36% Didn't Meet
Bundle 64%
All Sepsis Pre-mEWS Compliance to ABX in 3hrs
CONCLUSIONS/RECOMENDATIONS
• While overall time to antibiotic administration was improved in the post mEWS cohort, due to the law of small numbers, longer data collection should be evaluated to capture true improvement with a larger sample.
• To capture true compliance to the three hour sepsis bundle, other components in addition to antibiotics including lactate measurement, blood culture collection and administration of fluids for hypotension or lactic acidosis should be measured and evaluated.
• Although we had an overall improvement, mEWS criteria may need to be altered to better capture the neutropenic cancer population, as these patients may be unable to mount the inflammatory response required to trigger mEWS as defined in the study.
5hrs 51 mins
3 hrs
2hrs 50 mns
3 hrs 1 min
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