Philips To Read More {c5751585 44ba 4d55 Aaf5 69d1ebe14191} Decision Support Evidence Series VITAL Study Whitepaper 452296291321 LR
User Manual: Philips to read more Early Warning Scoring tools for rapid response
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July 24, 2013 Supplement to Decision Support Evidence Series whitepaper “Study finds benefits of spot check monitoring with early warning scoring” Instructions on Use and Distribution The Decision Support Evidence Series document “Study finds benefits of spot check monitoring with early warning scoring” summarizes background, purpose, methods, and results of the research paper “A controlled trial of electronic automated vital signs monitoring in general hospital wards” (“VITAL care” study). The research paper was peerreviewed and published in the August 2012 issue (Vol. 40, No. 8) of the medical journal “Critical Care Medicine”. When discussing this document with third parties or distributing it, please make sure to convey the following: The whitepaper is a promotional piece from Philips and may not be positioned as being published by an objective third party. The purpose of the whitepaper is to summarize the results of the “VITAL care” study. With respect to the following statement (made in the whitepaper): “The multicenter trial found the addition of the MP5SC with EWS to the hospitals’ existing protocol was associated with a 6.3% increase in survival rate at the end of the RRT call among patients who received such a call. “, it is not Philips’ intent to draw separate conclusions or make claims about the performance or capabilities of our product (MP5SC monitor with IntelliVue Guardian Solution). Thank you for following these instructions. Management Monitors & Measurements, Philips Medical Systems Philips Healthcare Simplifying clinician workflow • Improving financial outcomes • Helping improve and save lives Decision Support Evidence Series Study finds benefits of spot check monitoring with early warning scoring 1 Rinaldo Bellomo, MD, FRACP, FCICM; Michael Ackerman, RN, PhD; Michael Bailey, PhD, MSc; Richard Beale, MB, BS, MD, FRCA; Greg Clancy, RN, MSN; Valerie Danesh, PhD; Andreas Hvarfner, MD, PhD; Edgar Jimenez, MD; David Konrad, MD, PhD; Michele Lecardo, RN, BSN, CCRN; Kimberly S. Pattee, RN, BSN; Josephine Ritchie, RN; Kathie Sherman, RN; Peter Tangkau, MD; The Vital Signs to Identify, Target, and Assess Level of Care Study (VITAL Care Study) Investigators From the Department of Intensive Care (RB), Austin Health, Melbourne, Australia; Division of Nursing (MA), University of Rochester Medical Center, Rochester, NY; Department of Biostatistics (MB), Australian and New Zealand Intensive Care Research Center, Melbourne, Australia; Department of Critical Care Medicine (RB), St. Thomas’ Hospital, London, UK; Department of Nursing (GC, KSP), Mercy Hospital, Iowa City, IA; Department of Medical Intensive Care (VD, EJ), Orlando Regional Medical Center, Orlando, FL; Department of Intensive Care Medicine (AH), University of Lund Hospital, Lund, Sweden; Department of Intensive Care Medicine (DK), Karolinska Hospital, Stockholm, Sweden; Division of Nursing (ML), Norwalk Hospital, Norwalk, CT; Department of Critical Care Medicine (JR), Norwalk Hospital, Norwalk, CT; Department of Nursing (KS), Reinier MelroseWakefield Hospital, Melrose MA; Department of Intensive Care Medicine (PT), Reinier de Graaf Hospital, Delft, The Netherlands. Background Patients expect the utmost care and vigilance when admitted to a hospital. But studies have shown that preventable, serious adverse events are nonetheless common among hospitalized patients.2,3,4,5,6,7 As one bulwark against avoidable adverse events, clinicians can compare patients’ vital signs measurements against standard criteria to identify when a patient’s physiological condition is in danger of worsening. In response, hospitals have made an effort to reduce adverse events through early identification of patients displaying early warning signs of deterioration, and quick initiation of treatment. To that end, some hospitals have deployed a Rapid Response Team (RRT) also known as Medical Emergency Team (MET) or Critical Care Outreach Team that clinicians can notify when patients show evidence of deterioration based on early warning sign criteria set by the hospital. Still, studies have shown that clinician notification is a weak link in this system, relying on correct, timely interpretation of accurate measurements and 24-hour vigilance. Any deviation from this ideal can lead to nonactivation or delayed activation of the RRT, which is associated with increased mortality. 8,9,10,11,12,13,14,15,16,17,18 Purpose From August 2009 to June 2010, the authors performed a multi-centre, multinational, before and after controlled trial. The study paper was peer-reviewed and published in Critical Care Medicine in August, 2012 (Volume 40, number 8). The purpose of the study was to assess if, compared with standard paper-based systems, an automated Early Warning System (EWS) as part of a spot check patient monitor can help to identify patients in acute care settings (outside of the intensive care unit) who may be experiencing physiological instability and who are in need of prompt clinical intervention by an RRT. Methods The study looked at 10 hospitals in the United States, Europe, and Australia, consisting of 12 general wards and 349 beds. A total of 18,305 patients were included in the study: 9,617 in the control group (before the intervention) and 8,688 after the intervention. For the first three months of the study, before the intervention, the investigators collected data on the prevalence of serious adverse events, RRT activation, and patient outcomes among the control group of patients. Electronic vital signs monitors, Philips IntelliVue MP5SC, were then introduced to the wards. These monitors displayed the following patient vital signs during nursing spot checks: temperature, blood pressure, heart rate, and pulse oximetry. During the spot checks, the monitors also prompted clinicians to input information on respiratory rate, conscious state, and other optional parameters. See Figure 1. Based on criteria set by each hospital, the monitors used these measurements to calculate an early warning score for the patient. The MP5SC fully adopted the existing hospital EWS protocols, which were different and individualized for each site. These EWS protocols were already in place during the control phase. Figure 1: The flexible MP5SC patient monitor with built-in IntelliVue Guardian EWS can be used in spot-check as well as continuous monitoring mode. 2 The MP5SC with EWS displayed a color-coded status for the patient on the monitor screen—either “safe range” (white), “observe range” (yellow), “warning range” (orange), or “urgent range” (red). See Figure 2. The monitors stored measurements for review and documentation, and could display measurement and scoring trends. During the three-month intervention period, the authors collected the same types of data as during the control period on adverse events, RRT activation, and outcomes. Results The trial found that using the MP5SC with EWS resulted in a significant time reduction for completing acquisition of vital signs, clinical observations and calculating the Early Warning Scores required by the hospital’s EWS protocol. Clinicians reported that the MP5SC with EWS was easy to use and helped them easily measure, evaluate, and document their patients’ vital signs and EWS scores. Conclusions The multi-center study found that the introduction of Philips IntelliVue MP5SC reduced the time it took for clinicians to obtain and record vital signs, as well as to calculate Early Warning Scores. The trial found the addition of the MP5SC with EWS to the hospitals’ existing protocol was associated with a 6.3 percent increase in survival rate at the end of the RRT call among patients who received such a call. For the same patients, survival to hospital discharge or 90 days-survival also showed a significant improvement. It also altered the proportion of RRT calls initiated because of respiratory criteria, an important early warning sign for deteriorating condition. All of the study sites had individualized EWS and call escalation protocols in place before and during the control phase, indicating that the MP5SC with EWS can improve even an already established manual EWS process. Overall, the study’s findings point to automated monitoring as a way to increase the safety and improve the outcomes of patients in a hospital’s general wards. Figure 2: Screen display illustrating the function of the MP5SC monitor. In this display, the patient has abnormal respiratory rate (RR), temperature and level of consciousness (LOC) identified by colored circles (sub-scores). The monitor also calculates the MEWS score (6) and displays the recommended actions according to the institution’s EWS protocol. EWS, early warning score; MEWS, Modified Early Warning Score; NBP, noninvasive blood pressure; Pleth, pulse oximetry plethysmography. References 1. Bellomo R, Ackerman M, Bailey M, et al. A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards. Crit Care Med. 2012;40(8):2349-2361. 2. Brennan TA, Leape LL, Laird NM, et al: Harvard Medical Practice Study I: Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care 2004; 13:145-151; discussion 151. 3. Baker GR, Norton PG, Flintoft V, et al: The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170:1678-1686. 4. Vincent C, Neale G, Woloshynowych M: Adverse events in British hospitals: Preliminary retrospective record review. BMJ 2001; 322:517-519. 5. Buist MD, Jarmolowski E, Burton PR, et al: Recognizing clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust 1999; 171:22-25. 6. Bellomo R, Goldsmith D, Uchino S, et al: A prospective before-and-after trial of a medical emergency team. Med J Aust 2003; 179:283-287. 7. Buist M, Harrison J, Abaloz E, et al: Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ 2007; 335:1210-1212. 8. Buist M, Bellomo R: MET: The emergency medical team or the medical education team? Crit Care Resusc 2004; 6:88-91. 9. Devita MA, Bellomo R, Hillman K, et al: Findings of the first consensus conference on medical emergency teams. Crit Care med 2006; 34:2463-2478. 10. England K, Bion JF: Introduction of medical emergency teams in Australia and New Zealand: A multicenter study. Crit Care 2008; 12:151. 11. Casamento AJ, Dunlop C, Jones DA, et al: Improving the documentation of medical emergency team reviews. Crit Care Resusc 2008; 10:29. 12. Cretikos MA, Chen J, Hillman KM, et al: MERIT Study Investigators: The effectiveness of implementation of the medical emergency team (MET) system and factors associated with use during the MERIT study. Crit Care Resusc 2007; 9:206-212. 13. Jones D, Bellomo R, Bates S, et al: Patient monitoring and the timing of cardiac arrests and medical emergency team calls in a teaching hospital. Intensive Care Med 2006; 32:1352-1356. 14. Downey AW, Quach JL, Haase M, et al: Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med 2008; 36:477-481. 15. Quach JL, Downey AW, Haase M, et al: Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care 2008; 23:325-331. 16. MERIT study investigators: Introduction of the medical emergency team (RRT) system: A cluster-randomised controlled trial. Lancet 2005; 365:2091-2097. 17. Chen J, Bellomo R, Flabouris A, et al: MERIT Study Investigators for the Simpson Centre ANZICS Clinical Trials Group: The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37:148-153. 18. Cretikos M, Chen J, Hillman K, et al: MERIT study investigators: The objective medical emergency team activation criteria: A case-control study. Resuscitation 2007; 73:62-72. 3 Descriptors of monitoring and process of care in relation to all rapid response team calls* Descriptor Control Intervention Rapid response team dose (calls / 1000 admissions) 21.3/1,000 24.1/1,000 Age 68.0 (16.7) 69.4 (16.0) Male 106 (53%) 106 (52%) Number of vitals sets 24hr before call 5.2 (3.5) 5.7 (4.1) Number of vitals sets 48hr before call 9.9 (6.4) 10.2 (6.8) Number of abnormal vital signs at the 4 [2-6] 3 [1-5] time of rapid response team call Emergency admission to intensive care unit 55 (27%) 61 (29%) Transfer to higher acuity ward 75 (41%) 96 (49%) Do-not-attempt-resuscitation orders before call 19 (11%) 24 (12%) Do-not-attempt-resuscitation orders after call 19 (11%) 33 (17%) Surgical emergency admission 49 (25%) 52 (25%) Surgical elective admission 35 (18%) 28 (14%) Medical emergency admission 110 (56%) 125 (61%) Medical elective admission 2 (1%) 0 (0%) Triggered by respiratory signs 37 (21%) 61 (31%) Triggered by hypotension 32 (18%) 35 (18%) Triggered by neurological change 14 (8%) 10 (5%) Triggered by arrhythmia 22 (12%) 29 (15%) Triggered by staff concern 23 (13%) 17 (9%) Triggered by other factors 17 (10% 24 (12%) Triggered by multiple factors 32 (18%) 22 (11%) p 0.21 0.39 0.75 0.19 0.68 0.029 0.64 0.13 0.68 0.10 0.96 0.24 0.35 0.24 0.029 0.92 0.26 0.53 0.17 0.44 0.06 Table 1 RRT, rapid response team The time between documented presence of an institutionally sanctioned calling criterion and actual RRT attendance is expressed as mean with range;Vitals = vital signs (respiratory rate, heart rate, blood pressure, temperature, pulse oximetry, conscious state); DNR = do not attempt resuscitation; Elective = planned admission; Emergency = unplanned hospital admission. End of RRT intervention = the time when the RRT left the patient’s bedside. * Data for individual hospitals is presented in a Tables Appendix 2, Bellomo R,Ackerman M, Bailey M, et al.A controlled trial of electronic automated advisory vital signs monitoring in general hospital wards. Crit Care Med. 2012;40(8):2349-2361. Please visit www.philips.com/evidence © 2013 Koninklijke Philips N.V. All rights are reserved. Philips Healthcare reserves the right to make changes in specifications and/ or to discontinue any product at any time without notice or obligation and will not be liable for any consequences resulting from the use of this publication. Philips Healthcare is part of Royal Philips www.philips.com/healthcare healthcare@philips.com Printed in The Netherlands 4522 962 91321 * AUG 2013
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