M27 Should there be a Respiratory-specific Modified Early Warning Score?

Introduction The Modified Early Warning Score (MEWS) was developed and validated as an objective scoring system to aid healthcare staff in identifying patients at risk of “catastrophic deterioration” in the acute hospital setting(1). At the Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT), the Acute Response Team (ART) is led by advanced nurse practitioners, who respond to calls when patients have a MEWS of 4 or more. It was noted that a large proportion of calls were to respiratory patients, many requiring no intervention. Methods Details of every ART call to medical patients throughout 2012 (n = 883) were recorded on clinical proforma and collated on an Excel database. Data were analysed using STATA 12, as part of a service evaluation. Outcomes measured were: numbers of ART calls made to respiratory and remaining medical wards, numbers of Do Not Attempt Resuscitation (DNAR) orders in place, MEWS, investigations performed by the ART, critical care transfer and the 7 and 30 day mortality. Results The 53 respiratory beds account for only 14% of the medical bed-base but generated 25% of ART calls. Respiratory patients scored more highly on respiratory rate (RR) and oxygen saturations (SpO2) MEWS parameters than other medical patients. ART investigation rates were similar in all patients but only 1% were transferred from respiratory to critical care. There were more DNAR orders and both 7 and 30 day mortality were higher on the respiratory wards (see Table 1). Abstract M27 Table 1. Summary of ART calls for all of medicine, medicine (not respiratory) and respiratory only. Variable All medicine Medicine (not resp) Respiratory ART call total n, (%) 883 (100) 663 (75.1) 220 (24.9) DNAR in place 206 (23.3) 135 (20.4) 71 (32.3) MEWS MEWS (Respiratory Rate 0 194 (22.3) 158 (24.2) 36 (16.7) 1 286 (32.9) 213 (32.6) 73 (33.8) 2 177 (20.4) 130 (19.9) 47 (21.7) 3 206 (23.7) 147 (22.5) 59 (27.3) MEWS (Sp02) 0 112 (13.0) 99 (15.3) 13 (6.0) 1 252 (29.2) 214 (33.1) 38 (17.5) 2 203 (23.5) 145 (22.4) 58 (26.7) 3 296 (34.6) 189 (29.2) 107 (49.3) ITU/HDU referral 18 (2.0) 16 (2.4) 1 (1.0) BiPaP commenced 10 (1.1) 2 (0.3) 8 (3.6) 7 day mortality 237 (26.8) 164 (24.7) 73 (33.2) 30 day mortality (cumulative) 239 (27.1) 183 (28.0) 76 (36.0) Discussion Many respiratory patients score highly on RR and SpO2 MEWS parameters due to their chronic disease. The increased use of DNAR orders in respiratory patients reflects a greater burden of chronic disease and therefo