Early Warning System in Action

E4ED 2019, Dyandra Convention Center Surabaya

Early Warning System – DISASTER
 Sistim untuk menyelamatkan nyawa terhadap kejadian
bencana baik disebabkan karena air atau
geometeorologi
 Walaupun kerugian material tetap besar, namun
kehilangan nyawa secara global dapat ditekan dalam
kisaran faktor 10 ( tanpa EWS yang meninggal 1000,
dengan EWS yang meninggal 100 orang )
 Dipakai untuk monitoring, memprediksi dan
persiapan keadaan kegawatan yang efektif
 Deteksi/identifikasi Analisa risiko

EWS

Penyampaian tepat
Tindakan
waktu

I. Detection, monitoring and forecasting the hazards

II. Analyses of risk involves
III. Dissemination of timely warnings
IV.Activation of emergency plans to prepare and respond
 Di Rumah Sakit , hampir tiap hari ada kejadian
pasien meninggal, yang seharusnya tidak
meninggal ( die unnecessary).
 Tiap hari di RS terdapat 10 % pasien yang
mengalami kejadian yang tidak diharapkan,
 Penyakit pasien makin komplek, banyak ko-
morbid
 Beberapa diantaranya pada suatu ketika akan
mengalami perburukan/kegawatan secara tiba2,
karena berbagai sebab
 Tiap rumah sakit harus mempunyai strategi atau
sistim untuk mengidentifikasi pasien tersebut
 Intervensi dini akan memperbaiki outcome
 Studi observasional menunjukkan bahwa
seringkali pasien sudah mengisyaratkan adanya
tanda-tanda perburukan 24 jam sebelum
terjadinya keadaan yang mengancam nyawa
 Keterlambatan penanganan atau penanganan
yang tidak memadai di ruangan perawatan akan
meningkatkan admisi ke ICU, meningkatkan
lama perawatan – biaya, kejadian cardiac arrest
bahkan kematian
 30% pasien medis akut yang dirawat di RS yang
awalnya fungsi vital stabil, dalam 24 jam
pertama perawatan dapat mengalami
perburukan fungsi vital.
 43 % pasien yang mengalami perburukan fungsi
vital tidak terdeteksi oleh perawat ruangan

Penting !
Peran Perawat dalam deteksi
Perburukan kondisi pasien
 AHRQ’s Nationwide Inpatient Sample (NIS) -
2008
 US – 811.211 patients died in hospital
 28.887 Cardiac Arrest ( database – ICD 9 code 427.5) – overall
number CA in all US hospitals 144.435
 46 % of cardiac arrest occurred outside the ICU
– Bader et.al PMID 19435159
 18 % of general floor patients developed
abnormal vital sign ( three fold risk of mortality
compared to those with normal vital sign) –
Fuhrman 2008, Resuscitation 77(3): 325-30
Early Warning Scores System are tools used by
hospital care teams to recognize the early signs of
clinical deterioration in order to initiate early
intervention and management

1. Increasing nursing attention

2. Informing the health provider
3. Activating Rapid Response Team/
Medical Emergency Team
 Breathing problem & Increased respiratory rate
 Increased heart rate
 Hypotension
 Confusion
 Restlessness
 Lethargy or decrease Level of Consciousness
 Metabolic abnormalities

Early Signs of deterioration is happened

few hours before Cardiac Arrest
In 80 % acute medical patients
 1997, Morgan, Williams and Wright UK pertama kali
mengembangkan dan mempublikasikan EWS, terdiri
dari 5 parameter fisiologi
 Laju nadi – heart rate
 Tekanan darah sistolik – systolic blood pressure
 Laju pernapasan – Respiratory rate
 Suhu – Temperature
 Tingkat kesadaran – conscious level
(Clinical Intensive Care 8:100 )
 1999, Stenhouse membuat modifikasi EWS,
menambahkan parameter produksi urine
 Nurse concern juga dimasukkan kedalam EWS
 3 2 1 0 1 2 3
Pulse (bpm) ≤ 40 41-50 51-90 91-110 110-130 ≥ 131
RR (/min) ≤8 9-11 12-20 21-24 ≥25
Temp (OC) ≤ 35.0 35,1-36.0 36,1- 38,1-39,0 ≥ 39,0
38.0
Sys BP (mmHg) ≤ 90 91-100 101-110 111-199 ≥ 200
CNS - AVPU Alert V,P,U
 0

The RCP should be acknowledged as follows:

Reproduced from: Royal College of
Physicians. National Early Warning Score
(NEWS) 2: Standardising the assessment of
acute-illness severity in the NHS. Updated
report of a working party. London: RCP, 2017.
 Goal 16 : Improve recognition and response to
changes in a patient’s condition
 Goal 16A : The organization selects a suitable
method that enables health care staff members
directly request additional assistance from a
specialty trained individual when the patient
condition appears to be worsening
A System without Action
is
Nothing

RAPID RESPONSE TEAM

MEDICAL EMERGENCY TEAM

TRACT – TRIGGER – RESPONSE

 A team that can be activated to a patient
bedside to prevent the transfer of a patients
to intensive care unit, cardiac arrest or death
 Designed to rescue patients early in their
decline, before an adverse outcome occurs
 To save patients lives & eventually improve quality of
hospital care and improve patient safety
 Increase early intervention & stabilization to prevent
clinical deterioration on any individual prior to the event
of cardiopulmonary arrest or other life threatening health
event
 Decrease the number of cardiopulmonary arrest that
occur outside the ICU and ER department
 Increase patient, family and staff satisfaction
 Decrease mortality rate
 Reduce severe post-operative adverse events
 Person Peran Tugas
Dokter ICU Team leader Direct ACLS, medical decision
Perawat ICU /UGD Run medication / equipment Prepare medication,
cart equipment, defibrillator,
Perawat senior Ka- Recorder Coordinate data flow
Ruangan
Perawat ruangan Bedside nursing Delivery medication, VS , IV
functiion
Dokter anestesi Airway management Ventilation and oxygenation
Respiratory Care Airway assistant Oxygen supply, suction
Dokter umum Chest compression 30 : 2
Dokter spesialis Procedure physician Performed required procedure :
CVC, thoracostomy, BGA
 Moon et.al 2010, conducted an eight year audit of
outcome, including 4 years before and 4 years after the
introduction of MEWS , result : significant reduction in
both deaths (1,4% to 1,2%) and cardiac arrest ( 0,4% to
0,2% ) between the two periods (Resuscitation Feb
82(2) : 150-4)
 Cincinnati Children hospital, mortality decrease from
11,5% to 0% in pediatric ICU after PEWS initiated
 Mercy Hospital Anderson reported a reduction in code
blue from 0,77/1000 days to 0,39/1000 days (Maupin
2009 PMID 200434)
The value of Modified Early Warning Score
(MEWS) in surgical in-patients: a prospective
observational study
J GARDNER-THORPE, N LOVE, J WRIGHTSON, S WALSH, N KEELING
Ann R Coll Surg Engl 2006; 88: 571–575

PATIENTS AND METHODS A total of 334 consecutive ward patients were

prospectively studied. MEWS were recorded on all patients and the primary end-
point was transfer to ITU or HDU.
RESULTS :
1. Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring four
or more on MEWS.
2. Emergency patients were more likely to trigger the system than elective
patients.
3. Sixteen (5% of the total) patients were admitted to the ITU or HDU.
4. MEWS with a threshold of four or more was 75% sensitive and 83% specific for
patients who required transfer to ITU or HDU.

CONCLUSIONS
The MEWS in association with a call-out algorithm is a useful and appropriate risk-
management tool that should be implemented for all surgical in-patients.
 No significant differences on mortality, cardiac arrest or
ICU admission. Subbee et al 2003. (Anaesthesia Aug
58(8):797-802)
 EWS + RRT throughout 108 English hospital
significant decrease in the number ICU admission, no
significant differences in mortality and length of stay –
(Gao 2007 Critical Care 11(5):R113)
 Formal meta – analysis for Cochrane Review – showed
no benefit to EWS (Intensive Care Medicine Apr 33(4) :
667-679)
 Staf klinis dilatih untuk mendeteksi ( mengenali)
perubahan kondisi pasien yang memburuk dan mampu
melakukan tindakan

 Elemen Penilaian :
1. Ada bukti regulasi pelaksanaan EWS
2. Ada bukti staf klinis dilatih menggunakan EWS
3. Ada bukti staf klinis mampu melaksanakan EWS
4. Tersedia pencatatan hasil EWS
Bagaimana proses EWS – RRT/MET berlangsung

RRT
 ALGORITME EWS – RRT/MET
ICU HCU
MET Call/
EWS RRT
High Risk

Low risk

TREAT IN THE WARD

Ward nurse Perburukan
Oxygen Therapy Fungsi vital
Fluid Management
IV access
Komponen I : Deteksi dini perburukan klinis, aktifasi
sistim, menggerakkan respon yang sesuai

Komponen II: Kesiapan petugas – SDM, dan Fasilitas

untuk menunjang respons tersebut E
Komponen III : mutu - auditing – monitoring –
W
evaluasi untuk meningkatkan pelayanan dan
keselamatan pasien
S
Komponen IV : manajemen – administratif ,
kepemimpinan, budaya safety, edukasi, proses untuk
implementasi dan mempertahankan sistim
 Pertemuan untuk sosialisasi EWS, mengapa
EWS sangat penting, bagaimana sistim EWS
dilaksanakan
 Pengingat EWS : name tag, meja nurse station,
lembar observasi
 Pelatihan ketrampilan asesmen pasien
 Mengembangkan sense of crisis
 Jangan mengacuhkan informasi , respek
terhadap segala informasi tentang kekhawatiran
kondisi pasien
1. Without clear sign of commitment from leadership, cultural
changes will not happen
2. Ensure that everyone in the hospital is convinced
3. Engage nursing that implementing EWS is not just extra
work, but also a way to validate their nursing instincts
4. Remember that warning – activating – response system is a
chain
5. Select a scoring system that works well within the facility
6. Develop policies and procedures to establish accountability
7. Documentation activities – timeliness, completeness,
correction
8. Clinical suspicion or EWS should trigger response
EARLY WARNING SCORES & MEDICAL EMERGENCY
TEAMS

Early Warning Score (EWS) systems use

patient's vital signs to identify those who are most
unwell and then provide escalated care to try to
prevent them deteriorating further. For the sickest
patients, this response consists of a Medical
Emergency Team (MET) which immediately
brings senior doctors and nurses experienced in
acute medicine to the bedside.