Research Utilization and Implementation: Determining 28-Day Mortality Rates for Sepsis Patients Admitted to ED Tony Ingoglia 104112531

Spring 2013 N204 Research May 30, 2013

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A. BRIEFLY identify and define the clinical problem in your area of nursing interest or expertise. Early identification of acute and at risk patients with sepsis upon admission to emergency rooms are necessary triage tools that can help nurses and doctors identify vulnerable patients and aid decisions such as the type of medical bed required (i.e., medical surgical bed versus ICU or CCU bed) and the appropriate interval for nursing observations and physician review. What tool is the best early identifying triage tool for sepsis patients admitted in ED at risk of deterioration, who might benefit from an increased level of attention: Modified Early Warning Score (MEWS), Mortality in Emergency Department Sepsis Score (MEDS), Early Warning Score (EWS)? B. List the three (3) data-based, research articles (in APA format) you selected to address the clinical problem indicated above: Article #1: Cei, M., Bartolomei, C., & Mumoli, N. (2009). In-hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score : a prospective study. The International Journal of Clinical Practice, 63, 591-595. doi : 10.1111/j.1742.2008.01986.x Article #2: Vorwerk, C., Loryman, B., Coats, T.J., et al. (2009). Prediction of mortality in adult emergency department patients with sepsis. Emergency Medicine Journal, 26, 254-258. doi :10.1136/emj.2007.053298 Article #3: Groarke, J.D., Gallagher, J., Stack, J., Aftab, A., Dywer, C., & Courtney, G. (2008). Use of an admission early warning score to predict patient morbidity and treatment success. Journal of Emergency Medicine, 25, 803-806. doi :10.1136/emj.2007.051425

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B. Using the 3 databased, research articles you selected and reviewed for this final exam, summarize each of their findings regarding your clinical problem of interest. Article #1: A prospective single center, cohort study investigating the Modified Early Warning Score (MEWS). Sample size was 1107 patients at a 64-bed medical ward in a public, non-teaching hospital in Italy. The patients were consecutively admitted from November 2005 to June 2006. Mean age of subject was 78 years old. MEWS, even when calculated once on admission, is a simple but highly useful tool to predict a worse in-hospital outcome. The results showed that patients with MEWS <4 were discharged after a mean stay of 8.3 days, and patients with MEWS greater than 5 were discharged after a mean stay of 9.4 days. The mean length of stay for patients who died was 7.7 days and 5.1 days was the mean permanence of transferred patients. Respiratory rate and level of consciousness had the highest correlation with mortality. This study demonstrates that the in-hospital mortality of elderly medical patients can be accurately predicted by means of a simple score from MEWS. This tool is used to identify a subset of patients at risk of deterioration, who might benefit from an increased level of attention (Cei, et al. 2009). Article #2: A retrospective cohort study of adult Emergency Department (ED) patients admitted with sepsis. This study was conducted on 307 patients in a large urban teaching hospital and large district general hospital to determine efficacy of Mortality in Emergency Department Score (MEDS), Modified Early Warning Score (MEW), and Near-Patient Test lactate levels (NPT) in predicting 28-day mortality in ED patients with Sepsis. Inclusion criteria included patients older than 16 years and ED diagnosis of sepsis. Patients were identified from the ED database. The primary outcome was 28-day mortality. They were included if they had sepsis, two or more systemic inflammatory

!"##$#%&'()*+&*(,(!-$#$#%&./0*)1&-2!,)3$,1&!),(4&25&4(64$4&6),$(#,4& & response syndrome criteria and a working diagnosis of infection documented in ED notes. Results from this study compared the efficacy of Mortality in Emergency Department Sepsis Score (MEDS), Modified Early Warning Score (MEWS) and Near-Patient-Test Lactate Levels (NPT). These results demonstrated that MEDS score was found to be the best performing risk assessment model which, with prospective validation, may aid early clinical decision-making in ED patients with sepsis and might affect the outcome from sepsis (Vorwerk, et al. 2009). Article #3: A prospective study of 225 consecutive medical admissions in a 315-bed Irish General Hospital

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over a 30-day period. Pulse, systolic blood pressure, respiratory rate, and neurological status was used to calculate Early Warning Score. Endpoints examined are ICU/CCU admission, death, cardiac arrest, and length of hospital stay. Patients were followed for the duration of their hospital admission. Odds and ratios were estimated with EWS category as the independent variable while the dependent variables were admissions to CCU/ICU, survival to discharge, and combined ICU/CCU death outcomes. The study demonstrates that for unselected medical admissions, an increased Early Warning Score on admission predicts increased mortality, increased likelihood of admission to ICU and CCU, death and longer length of hospital stay. The EWS could therefore be used as a triage tool in the emergency department for acute medical patients and identify at risk patients from the outset. This study demonstrates that the trend between EWS on arrival and before transfer to a ward is an early predictor of outcome and treatment success (Groarke, et al. 2008). C. Synthesize the results of the 3 studies by drawing conclusions about the solution to your clinical problem. Although all three assessment models demonstrated the potential of an early risk-stratifying tool for patients with sepsis, the MEDS score was found to be the best overall discriminator for

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identifying high-risk patients. Identifying high-risk patients in need of early goal-directed therapy (early recognition and hemodynamic optimization) through MEDS will lead to significant reduction in mortality. The MEDS score may also have the potential to be used as a rule-out tool since patients with an abbreviated MEDS score of equal to or less than 5 have a very low mortality of 1.6% (98% sensitivity) (Vorwerk, et al. 2009). Conversely, the abbreviated MEDS score has the potential to identify a group of patients where aggressive therapy is futile, since a MEDS score of greater than 16 in our cohort had a 98.7% specificity for 28-day mortality. MEDS score could facilitate clinical decisions and highlight at risk sepsis patients upon assessment and determine which ward to send patients as well as level of attention depending on projected patient needs. Phase II: Comparative Evaluation Phase A. Fit of Setting - Are these solutions (findings) appropriate or inappropriate for you to use in your clinical setting? These assessment tools are useful for critically ill patients in the Emergency Department for admittance of patients with Sepsis to determine high risk and 28-day mortality. CITATION Cei, M., Bartolomei, C., & Mumoli, N. (2009). In-hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score : a prospective study. The International Journal of Clinical PURPOSE Prospective single centre, cohort study investigating the ability of the MEWS to identify a subset of patients at risk of detioration, who might benefit from an increased level of SAMPLE/ SETTING N=1107 patients admitted, 996 patients were discharged, 102 deceased, and 39 were transferred at a 64-bedded medical ward in a public, nonteaching hospital in Italy. All patients were consecutively admitted from November 2005 to June 2006. Mean METHODS On admission five physiological paramters were measured: systolic blood pressure, pulse rate, respiratory rate, body temperature and level of consciousness (AVPU score). Statistical analysis was RESULTS The range of admission scores varied from 0 to 10. Patients with MEWS <4 were discharged after a mean stay of 8.3 days, and alive patients with MEWS greater than 5 were discharged after a mean stay of 9.4 days. The mean length of stay for DISCUSSION & LIMITATIONS The study clearly demonstrates that the in-hospital mortality of elderly medical patients can be accurately predicted by means of a simple score. The study has also proven that all the parameters of the MEWS are important, the

!"##$#%&'()*+&*(,(!-$#$#%&./0*)1&-2!,)3$,1&!),(4&25&4(64$4&6),$(#,4& & Practice, 63, 591- attention. 595. doi : 10.1111/j.1742.200 8.01986.x age of 621 females: 80.6 years. Mean age of 486 men: 77.1 years. performed with Epi-Info software. For continuous variables they calculated mean, median, mode, range and confidence intervals. Employed twotailed Student ttest for confronts. Dichotomous variables and trends were analyzed with the yates correction or Fisher exact test. Odds ratio calculated with 95 % confidence and p value was less than 0.05 as statistically significant. N= 307 ED patients Patients were with sepsis adult identified from ED admitted to the hospital was computerized conducted in a large ED database. urban teaching They were hospital and large included if they district general had an ED hospital. There diagnosis of were 72 deaths. sepsis, two or more systemic inflammatory response syndrome criteria and a working diagnosis of patients who deceased was 7.7 days and 5.1 days was the mean permanence of transferred patients. Among the physiologic parameters, respiratory rate and level of consciousness had strongest correlation to mortality, whereas temperature was the weakest but still significant.

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most useful being the level of consciousness. However, the data was collected in a non-teaching hospital with scarcity of both physicians and nurses to apply the MEWS to a large number of unselected elderly patients. Also the study was not able to record the 30day mortality, so data from patients discharged should be disregarded.

Vorwerk, C., A Loryman, B., Coats, retrospective T.J., et al. cohort study Prediction of of adult ED mortality in adult patients with emergency sepsis department patients admitted to with sepsis. hospital was Emergency conducted in Medicine Journal, a large urban 26, 254-258. teaching doi :10.1136/emj.20 hospital and 07.053298 large district general hospital. To determine efficacy of

MEDS score was 98.6% sensitive and 93.2% specific for mortality in highrisk patients. The MEWS score was 72.2% sensitive and 59.2% specific to mortality in highrisk patients. The NPT lactate level was 49.1% sensitive and 74.3% specific to mortality in high-

With retrospective studies, the data included and their accuracy are dependent on the original ED note keeping, thus there is a potential for bias. There is possibility that patients with sepsis were missed during the study period if they were given the wrong ED discharge code or did not have

!"##$#%&'()*+&*(,(!-$#$#%&./0*)1&-2!,)3$,1&!),(4&25&4(64$4&6),$(#,4& & MEDS, MEW, and NPT in predicting 28 day mortality in ED patients with sepsis. Inclusion criteria were age greater than 16 years and ED diagnosis of sepsis. Groarke, J.D., A prospective Gallagher, J., Stack, study of 225 J., Aftab, A., consecutive Dywer, C., & medical Courtney, G. admissions. (2008). Use of Pulse, systolic an admission early blood warning score to pressure, predict patient respiratory morbidity and rate, and treatment success. neurological Journal of status used to Emergency calculate Medicine, 25, 803- EWS. 806. Endpoints doi :10.1136/emj.20 examined are 07.051425 ICU/CCU admission, death, cardiac arrest, and length of hospital stay. infection documented in ED notes. Patients were excluded if parameters to calculate the MEW or MEDS score were missing. The primary outcome was 28-day mortality. Patients were followed for the duration of their hospital admission. Odds and ratios were estimated using logistic regression with EWS category as independent variable and dependent variables included: admit to CCU/ICU, survival to discharge and combined CCU/ICU death outcomes. risk patients. MEDS score is a good predictor of 28-day mortality, the MEW score is an acceptable predictor of 28day mortality, and NPT lactate levels are a poor predictor od 28day mortality. Increased EWS on admission predicts increased mortality, increased likelihood of admission to ICU or CCU, death and a longer length of hospital stay.

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blood cultures obtained in the ED.

N= 225 patients consecutively admitted to 315 bed Irish general hospital over a 30 day period.

The small number of patients overall and in particular the small number of patients in the higher score categories are limitations. Oly acute medical patients are considered and patients from other specialties are not considered. This is a considerable bias.

B. Substantiating Evaluation Were the results the same for all 3 studies? In the first study, the MEW score could not determine 28-day mortality but was stated to be an adequate tool to assess high-risk patients. In second study, the MEDS score was found to be the best performing risk assessment model for high-risk and 28-day mortality patients with sepsis

!"##$#%&'()*+&*(,(!-$#$#%&./0*)1&-2!,)3$,1&!),(4&25&4(64$4&6),$(#,4& & in the ED compared to MEW score and NPT lactate levels. The EWS has been proven potentially useful to use as a triage tool and used in the pre-hospital setting to alert the receiving hospital of critically ill patients. EWS doesnt determine 28-day mortality.

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C. Basis for Practice - What is the intervention (suggested by your review of the literature) for the clinical problem you would like to investigate or evaluate for use in your clinical setting? Incorporate an evidence-based model of your choice answer into your description of the problem/intervention. Identifying high-risk patients in need of early goal-directed therapy (early recognition and hemodynamic optimization) through MEDS will lead to significant reduction in mortality. The MEDS score may also have the potential to be used as a rule-out tool since patients with an abbreviated MEDS score of equal to or less than 5 have a very low mortality of 1.6% (98% sensitivity) (Vorwerk, et al. 2009). Conversely, the abbreviated MEDS score has the potential to identify a group of patients where aggressive therapy is futile, since a MEDS score of greater than 16 in our cohort had 98.7% specificity for 28-day mortality. MEDS score could facilitate clinical decisions and highlight at risk sepsis patients upon assessment and determine which ward to send patients as well as level of attention depending on projected patient needs.

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D. Feasibility 1. What are the benefits of using this suggested solution in your clinical setting? A) The MEDS score will enable my unit to rule out high-risk patients and place them in medical surgical units rather than ICU/CCU. B) The MEDS score has capacity to determine high-risk patients and rapidly admit sepsis patients to ICU/CCU. Using this scoring method will also initiate early goal directed treatment that can significantly reduce mortality in sepsis patients. C) The MEDS score has the potential to identify a group of patients where aggressive therapy is futile, since a MEDS score of greater than 16 in our cohort had a 98.7% specificity for 28-day mortality. If therapy is determined to be futile, staff can implement POLST forms for the family to determine if end of life care or possibly transfer patient to palliative care upon consultation with family. D) Trained paramedics can potentially apply the MEDS score in the pre-hospital setting. The MEDS is the optimum tool that can be calculated my paramedics and help them identify if

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they are at high risk of needing acute treatment from ICU/CCU. The advantage of using MEDS in the pre-hospital setting is to alarm emergency departments that incoming patients have sepsis. Result: All of these benefits are measures of better use of hospital/staff resources and cost reduction. MEDS score also can alleviate suffering by bypassing aggressive ICU/CCU therapy if 28-day mortality is imminent. 2. What are the disadvantages of using this suggested solution in your clinical setting? MEDS can predict the 28-day mortality of patients with sepsis. However, deaths related to sepsis may have occurred. It is not yet determined, but this risk assessment tool may not be as accurate to predict 28-day mortality if the patient doesnt have sepsis. Phase III: Decision-Making Phase A. Describe the pilot study you would need to implement to test out the proposed solution for use in your clinical setting. Briefly describe the purpose and method. Physician Orders for Life-Sustaining Treatment is a form that allows what kind of end of life care septic patients prefer. MEDS score higher than 16 have 98.6% chance of 28-day mortality. The MEDS >16/POLST program will take patients with scores higher than 16 and educate and inform patient and family to initiate POLST when the patient has the ability to early on rather than closer to end-point. Printed on bright pink paper, and signed by both a doctor and patient, POLST helps give serious ill patients more control over their end-of-life care. The sample was derived from a list of all staff involved in the admission of septic patients with MEDS score >16 between 2011-2013. Survey packets will be mailed to 200 potential nurse and physician respondents.

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survey, a postage-paid return envelope, and a copy of the POLST form. Return envelopes will be coded to enable tracking of non-responders, and completed surveys were separated from these return envelopes to ensure the anonymity of the responses. Individuals will not respond will be sent a reminder postcard 2 weeks after the initial mailing and a second survey packet approximately 2 weeks after the reminder postcard. The survey is divided into !ve sections with 22 close-ended-questions, one seven-part question, and three open-ended questions. The first section includes demographic questions. The section includes questions about any education they gave to the patient regarding the POLST program, community use of the POLST, and personal exposure to MEDS >16 patients with a POLST form. Only respondents who indicated that they had treated a patient with a POLST form were instructed to complete the section which includes questions about their experience based on the most recent patient treated with a form. In Section 4, all participants were asked to share their opinions about the utility of the POLST form, using a 5-point Likert scale ranging from 1 (strongly disagree) to 3(neutral) to 5 (strongly agree). All participants will be asked to provide feedback about the POLST program in response to open-ended questions, including questions about community barriers to use of the POLST program, problems with the POLST form in the unit, and how the POLST program had been helpful to them in the unit. Using double entry to assure accuracy, data were entered into Microsoft ACCESS version 2000. The data were then imported into SPSS version 11.5 for analysis. Summary statistics included proportions and tests for trends for categorical variables and means with standard deviations for continuous variables. The Mantel-Haenszel method was used to estimate a common odds ratio (OR) for dichotomous variables. Post hoc comparisons of

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Pearson chi-square (w2) test of independence. For purposes of analysis, the 5-point Likert scale was collapsed to agree, neutral, disagree. Because multiple comparisons were made, an alpha level of Po.025 was considered significant. B. Identify the persons or groups that must accept and implement this change Physicians, nurses, and patients must accept and implement this change. Nurses can assess patients that contributes to MEDS score but Physicians validate the MEDS score and they must be cosigners with the patient on their POLST. Nurses cannot sign POLST with patients. C. What are the motivations for change for these persons/groups? Knowing early that a septic patient has extremely high likelihood of death, rapid implementation of what kind of medical treatment the patient wishes to have improves their quality of life and personal autonomy. This measure also has power to bring families together to influence POLST and reduce lawsuits if they did not like the how medical treatment was handled at end-of-life. Implementing POLST early leads to higher patient satisfaction as well as nursing and medical staff satisfaction by improving coordination of care. C. What are the barriers to change for these persons/groups? Some patients with high chance of 28-day mortality may not be ready to initiate POLST. If the patient is in denial about their possibility of death, the physician and nursing staff must respect their decision. E. Describe TWO methods to overcome these identified barriers to change: A) Educating the patient that POLST gives them more autonomy over their choices and preferences and that they can choose to receive maximal life-sustaining treatment or that they could choose comfort sustaining human death in hospice care.

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B) Arrange for patient to speak to doctor about what aggressive life sustaining treatment will be like and also arrange for patient or patients family to meet with a palliative care representative to discuss what it means to accept natural death and what type of comfort measures are implemented for patients during their course of stay. F. Communication of Findings - For each of the following groups, identify ONE (1) method to communicate the findings of your research utilization project: 1. Administration of the organization Submit my abstract to Association of Critical Care Nurses annual symposium for local chapter. Present my findings to conference audience. There will likely be administrators from my CCU/ICU unit that will hear the validity of my research project and the potential for the hospital to improve patient satisfaction and improve cost reduction in high acuity units. 2. Staff nurses Joining a journal club on my unit will be a useful way of discussing my own research. Also, creating a poster to put in the unit floor educating staff on MEDS score and POLST will allow them to gain insights into how administering POLST to sepsis patients with MEDS >16 can improve outcomes for the patient, family, nurses, and physicians in collaborative care of the patient. 3. Ancillary health care personnel (ex: physicians) It is important for the physicians to understand that they play a crucial role in administering MEDS scores for patients with sepsis in predicting 28-day mortality rate. They also play a crucial role in completing POLST forms with patients or their power-of-attorney. Physicians need to understand the benefits of improved collaborative care with nurses and multi-disciplinary care team as well as transferring terminal patients who prefer acceptance of natural death to hospice units. Better satisfaction of patients and improved allocation of resources and technology creates a more

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As the patient reflects on and expresses her/his wishes, have the patient write her/his wishes down in an Advance Directive document. An Advance Directive is a statement, shared with both family and the doctor, about how she/he wants to be treated if she/he becomes seriously ill and cannot speak for herself/himself. I can also appoint a spokesperson a Healthcare Power of Attorney the patient or someone else who understands her/his wishes and will be able to speak for her/him if she/he is unable to do so (Coalition for Compassionate Care in California, 2013).

!"##$#%&'()*+&*(,(!-$#$#%&./0*)1&-2!,)3$,1&!),(4&25&4(64$4&6),$(#,4& & References Cei, M., Bartolomei, C., & Mumoli, N. (2009). In-hospital mortality and morbidity of

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elderly medical patients can be predicted at admission by the Modified Early Warning Score : a prospective study. The International Journal of Clinical Practice, 63, 591-595. doi : 10.1111/j.1742.2008.01986.x Coalition for Compassionate Care in California. (2013). Advance care planning- conversation guide. Retrieved from : http://www.coalitionccc.org/documents/Advance_Care_Planning_Conversation_Guide.pdf Groarke, J.D., Gallagher, J., Stack, J., Aftab, A., Dywer, C., & Courtney, G. (2008). Use of an admission early warning score to predict patient morbidity and treatment success. Journal of Emergency Medicine, 25, 803-806. doi :10.1136/emj.2007.051425 Vorwerk, C., Loryman, B., Coats, T.J., et al. (2009). Prediction of mortality in adult emergency department patients with sepsis. Emergency Medicine Journal, 26, 254-258. doi :10.1136/emj.2007.053298