Utilization of Modified Early Warning Score (MEWS) to Decrease In-hospital Cardiac

Arrests (IHCA)

A DNP Project Submitted to the

Graduate Faculty
of Jacksonville State University
in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Nursing Practice

By

Ashley E. Bryan

Jacksonville, Alabama

August 4, 2023
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Copyright 2023
All Rights Reserved

Ashley E. Bryan August 4, 2023

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Abstract

Background: Less than 25% of patients survive to discharge after an in-hospital cardiac arrest

(IHCA). The American Heart Association (AHA) aimed to increase the survival to discharge

after IHCA to 35%, according to the AHA Get with the Guidelines (GWTG). Pre-

implementation of MEWS-based rapid response rounding the facility had a 24% survival to

discharge rate after IHCA.

Purpose: The Doctor of Nursing Practice (DNP) project aimed to improve the survival to

discharge percentage after IHCA by implementing MEWS-based rapid response rounding on all

patients with a MEWS of four or greater.

Methods: The quality improvement project consisted of having rapid response nurses' round on

patients with a MEWS of four or greater. The rapid response nurses utilized the rapid response

protocols, triaged calls, and assessed patients while attending physicians were informed as

appropriate.

Results: Key results included a decrease in IHCA with MEWS-based rapid response rounding

from 0.80 to 0.25 IHCA per 1,000 occupied patient beds. The facility had one IHCA after

MEWS-based rapid response rounding was implemented. Unfortunately, the patient did not

survive to discharge, which did not improve the survival to discharge rate after IHCA. Since the

survival to discharge rate was not improved, the American Heart Association (AHA) Get with

the Guidelines (GWTG) goal of 35% was unmet. Additional vital results included decreased

rapid response calls from 31.2 to 29 rapid responses per 1,000 occupied patient beds. However,

there were fifty-one patients with an elevated MEWS or 12.8 MEWS per 1,000 occupied patient

beds. A decrease in the number of ICU transfers was also seen from 10.2 to 8.5 ICU transfers per

1,000 occupied patient beds.

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Conclusion: The DNP project helped stress the importance of utilizing MEWS-based rapid

response rounding to decrease the amount of IHCA that occurs and decrease the amount of ICU

transfers that occur. The DNP project revealed the facility did not meet the AHA GWTG goal of

35% of patients surviving to discharge after an IHCA. Additional investigation is needed to

determine the optimal method for improving survival to discharge after IHCA and decreasing the

number of IHCA that occurs.

Keywords: Modified Early Warning Scores, MEWS, in-hospital cardiac arrests, IHCA,

rapid response
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Acknowledgments

I want to express my most profound appreciation to the faculty at Jacksonville State

University for their assistance and guidance throughout the Doctor of Nursing Practice program.

I will forever thank Dr. Heather Wallace and Dr. Douglas Stephens for their extraordinary

support and encouragement. I would also like to thank my wonderful children, Kaylei, Rosalie,

William, and Asher, for their support during difficult school times. They have been helpful

throughout the project and inspired me to persevere through difficult times.

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Table of Contents 

Abstract……………………………………………………………………………………………3

Introduction…………………………………………………………………………………….….8

Background ………………………………………………………………………………….........8

American Heart Association Statistics………………………………………………….…8

In-Hospital Cardiac Arrests………………………………………………………….…....9

Rapid Response Teams……………………………………………………………............9

Modified Early Warning Scores……………………………………………………........10

Needs Analysis…………………………………………………………………………………...11

Problem Statement……………………………………………………………………………….12

Aims and Objectives……………………………………………………………………….…….13

Review of Literature……………………………………………………………………….…….13

Modified Early Warning Scores…………………………………………………………14

Donabedian Theoretical Framework……………………………………………….………….....16

Methodology…………………………………………………………………………………......17

Setting………………………………………………………………………….……..….17

Population…………………………………………………………………………….….17

Inclusion/Exclusion Criteria for the Population……………………….……………..….18

Design……………………………………………………………………………………18

Data Review Process…………………………………………………………...………...19

Risks and Benefits………………………………………………………….……....…....19

Timeline……………………………………………………………………….………....19
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Budget and Resources………………………………….……………………………..….20

Evaluation Plan……………………………………………………………………………….….21

Statistical Considerations……………………………………...…………………………21

Data Maintenance and Security………………………………………………………….21

Results…………………………………………………………………….………………...……22

Data Analysis…………………………………………………………………………….23

Discussion…………………………………………………………………………………….….23

Implications for Clinical Practice…………………………………….………...…….….23

Implications for Quality/Safety…………………………………………………...……...24

Implications for Education…………………………………………………….................24

Limitations……………………………………………………………………………………….24

Dissemination……………………………………………………………………………………25

Sustainability………………………………………………………………………….….………25

Plans for Future Scholarship………………………………………………………….….………25

Conclusion.……………………………………………………………………..………….…….25

References………………………………………………………………………………...……...27

Appendices………………………………………………………………………………….….......

Appendix A- CITI Training Certificate……………………………………...……..........31

Appendix B – JSU IRB Approval Letter ………….……………………………….........32

Appendix C – Project Timeline………..…………………………………………...........33

Appendix D – Data Comparison Graph……………..……………………………...........34

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Utilization of Modified Early Warning Score (MEWS) to Decrease In-hospital Cardiac

Arrests (IHCA)

Inpatient cardiac arrest is frequently associated with a high mortality rate (Anderson et

al., 2019). In-hospital cardiac arrest (IHCA) affects approximately 1% of individuals (Patel et al.,

2022). IHCA occurs annually in around 290,000 United States adults (Anderson et al., 2019).

Despite advances in IHCA medical treatment and management, the prognosis remains dismal

(Jung et al., 2022). Earlier recognition of patient deterioration is one way to improve patient

outcomes and decrease IHCA by utilizing modified early warning scores (MEWS) based rapid

response rounding. The MEWS tool is used on hospitalized patients to help clinicians predict

clinical deterioration and the potential need for a higher level of care earlier (MDCalc, 2022).

MEWS was founded on the premise that clinical deterioration can be detected through small

changes in several indicators and substantial changes in a single variable (MDCalc, 2022). This

study examines the use of MEWS by the rapid response team to reduce IHCA.

Background

Studies have shown MEWS assists with earlier recognition of the deterioration process

(Warren, 2021). MEWS is a physiologic scoring system utilized at the bedside by nursing staff to

identify patients at risk for clinical deterioration (Silva et al., 2021). A higher MEWS indicates a

patient with a worsening clinical status, and a rapid response team should be activated to respond

(Silva et al., 2021). 

American Heart Association Statistics

The AHA set a goal of doubling cardiac arrest survival by 2020 (Neumar, 2016). The

target survival rate for IHCA in 2020 was 35%, based on the IHCA survival rate in 2010 of 19%

(Neumar, 2016). The GWTG registry reported a survival rate of 23.8% in 2015 (Neumar, 2016).
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The GWTG registry reported data from 2008-2017, which showed an increased incidence of 9 to

10 IHCA per 1000 patient admissions (Anderson et al., 2019). GWTG registry reported a 25%

survival to discharge in 2017 (Anderson et al., 2019). Survival to hospital discharge was 22.4%

out of 33,874 adults in 328 hospitals, according to the GWTG 2020 data (Tsao et al., 2022). The

incidence of IHCA for adults was a mean of 17.16 per 1000 hospital admissions and 3.94 per

1,000 inpatient days in the 2020 GWTG data (Tsao et al., 2022).

In-Hospital Cardiac Arrests

The definition of cardiac arrest is the absence of a heartbeat and respirations, prompting

the need for high-quality cardiopulmonary resuscitation (CPR) (Patel et al., 2022). MEWS

facilitates observation of the patient's clinical condition before cardiac arrest (Anderson et al.,

2019). The International Society of Rapid Response Systems recommended hospitals collect data

on the potential predictability of IHCAs (Jung et al., 2022). Upon a retrospective chart review,

many IHCAs are considered preventable (Anderson et al., 2019). Before an IHCA, clinical

deterioration is common (Anderson et al., 2019). The 2015 AHA guidelines for CPR and

emergency cardiovascular care added prevention as the first link in the chain of survival for

IHCA patients (Anderson et al., 2019). An essential part of success includes identifying at-risk

patients and providing early interventions to prevent the patient's deterioration into cardiac arrest

(Anderson et al., 2019). Early warning systems triggered by specific vital sign abnormalities will

help identify patients at risk for deterioration (Anderson et al., 2019).

Rapid Response Teams

The Institute for Healthcare Improvement's 100,000 Lives Campaign recommended

hospitals implement rapid response teams to identify rapid deterioration in hospitalized patients

(Solomon et al., 2016). Multiple studies have shown the risk for IHCA is predictable, and
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focused rapid response teams may reduce the risk of IHCA (Tsao et al., 2022). Reduction of

IHCA was seen with rapid response team and medical emergency team to the emergency

department and acute care units (Mankidy et al., 2020). Hospital-wide cardiac arrests decreased

from 2.2 events per 1000 patient days to 0.8 events per 1,000 patient days in a combined rapid

response emergency response team (Mankidy et al., 2020). Pulseless electrical activity (PEA)

and shockable rhythms significantly decreased with rapid response emergency team response

(Mankidy et al., 2020).

While hospitalized, a patient with an acute deterioration often shows abnormal vital

signs, or warning signs, hours before experiencing an adverse clinical outcome (Patient Safety

Network, 2019). Usually, recognition of clinical deterioration in hospitalized patients occurs far

after the signs are initially present (Warren, 2021). Studies showed that implementing a rapid

response team reduces total intensive care unit (ICU) admissions (Al-Omari et al., 2019). Timely

identification of a patient's deterioration can prevent the escalation of care to an unplanned ICU

admission by prompting earlier intervention (Heal et al., 2016). Unplanned transfer to the ICU

contributes to 18-25% mortality rates for hospitalized patients (Frank et al., 2020). Transfer to

the ICU increases the hospital's length of stay overall (Frank et al., 2020).

Implementing a dedicated rapid response team reduced hospital mortality and IHCA. As

a result of the implementation of rapid response teams, the hospital mortality rate fell from 7.89

per 1000 hospital admissions to 2.8. (Al-Omari et al., 2019). IHCA incidence fell from 10.53 per

1,000 hospital admissions to 2.58 per 1,000 hospital admissions (Al-Omari et al., 2019).

Modified Early Warning Scores

An elevated MEWS during a rapid response is a valid predictor for an unplanned transfer

to an ICU due to patient deterioration (Kirsch et al., 2020). Utilization of MEWS-based rapid
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response rounding detects clinical deterioration before an unplanned ICU admission, or IHCA

occurs. MEWS involves the electronic health record assigning a number between zero and three

to each vital sign validated by nursing staff (Institute for Healthcare Improvement, n.d.).

Respiratory rate, heart rate, blood pressure, level of consciousness, temperature, and urine output

are all part of the MEWS data (Institute for Healthcare Improvement, n.d.). A MEWS of 4 has a

12.7% chance of ICU admission or death within 60 days (MDCalc, 2022). A MEWS of 5 has a

30% chance of ICU admission or death within 60 days, and recommends considering a higher

level of care (MDCalc, 2022). Patients demonstrate early warning signs or vital sign changes

from clinical deterioration within 8 hours preceding cardiopulmonary arrest (Heal et al., 2017).

Survival statistics of cardiopulmonary arrest patients are that fewer than 20% of resuscitated

patients survive to discharge from the hospital (Heal et al., 2017).

The proposed project and evidence-based intervention include implementing MEWS-

based rapid response rounding to decrease IHCA and unplanned ICU transfer. The facility had a

24% survival to discharge rate after IHCA which prompted a needed intervention to meet the

AHA GWTG of 35% survival to discharge after IHCA. Clinical implications include using

MEWS as a clinical tool at the bedside that predicts the patients' need for unplanned ICU

admission, LOS, cardiac arrest, and risk of mortality after the clinical deterioration (Kirsch et al.,

2020).

Needs Analysis

Rapid response teams aim to improve patient outcomes in the event of deterioration

based on a reactionary approach. The bedside nurse often initiates the process after abnormal

vital signs are present, placing the patient at an increased risk for IHCA. The facility does not

utilize the electronic health record's modified early warning scores list.
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Over the past thirteen months, the facility has had 25 IHCA, with only six patients surviving to

discharge. Out of the 25 IHCA, 20 patients, or 80% of patients, achieved a return of spontaneous

circulation and were transferred to the ICU. Underutilization of MEWS presented a survival to

discharge rate of 24% after IHCA at the facility, which fail below the AHA GWTG goal of 35%.

The hospital averaged 0.8 IHCA per 1,000 patient-occupied beds. There have been 31.2 rapid

responses per 1,000 patient-occupied beds on the inpatient floors where the project

implementation occurred. Additionally, the facility had 10.2 ICU transfers after rapid response

per 1000 patient-occupied beds. The average ICU admission rate after a rapid response without

implementing MEWS is 25%.

Early warning systems have recently been strongly recommended in guidelines to help

detect deteriorating patients earlier and treat them adequately (Heller et al., 2020). Earlier

detection of patient deterioration outside of the ICU improved by introducing a MEWS-based

early warning system (Heller et al., 2020). An elevated MEWS resulted in unplanned ICU

admission and a nearly 3-fold increased mortality risk (Kirsch et al., 2020). IHCA dropped from

5.3 to 2.1 per 1000 patient-occupied beds, and unplanned ICU transfers were reduced from 3.6%

to 3.0% with MEWS-based rapid response rounding (Heller et al., 2020).

Problem Statement

The facility's practice was rapid response activation after a medical emergency. The

problem identified a gap in service at the facility by not meeting the AHA GWTG survival to

discharge after the IHCA goal of 35%. The facility had a 24% survival to discharge rate after

IHCA before project implementation. The DNP project aimed to utilize MEWS-based rapid

response rounding to decrease the IHCA rate, improve the survival to discharge rate after IHCA

and improve the unplanned ICU transfers after rapid responses. The following PICOT statement
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will be explored: "Among non-ICU hospital patients, does the implementation of MEWS and

rapid response team rounding, as compared to rapid response team rounding after clinical

deterioration, decrease IHCA over six weeks."

Aims and Objectives

The evidence-based implementation of MEWS-based rapid response rounding provided

acute care and rapid response nurses with a clinical tool to determine patients at risk for

deterioration. The acute care nurses reviewed the MEWS on patient lists and notified the rapid

response nurses as needed if MEWS is elevated. The patients with a MEWS of greater than four

resulted in a list for the rapid response nurse to review. The rapid response nurse rounded on all

the patients with a MEWS of four or higher. The rapid response nurses utilized the protocols and

notified the physician of patient deterioration. Key clinical staff involved in the project include

nursing staff on medical-surgical, medical telemetry, cardiac telemetry, float pool nurses, house

supervisors, and rapid response nurses. Together, the nursing team carefully reviewed and

rounded on all patients with a MEWS of four or more higher. MEWS helped recognize patients

with a clinical deterioration. The DNP project aimed to intervene by rounding proactively on

patients with a MEWS of four or greater to decrease IHCA. The MEWS intervention may reduce

unplanned ICU admissions and increase rapid response notification.

Review of Literature

A literature review was performed with the following primary considerations: 1) Best

practice to improve survival to discharge after IHCA; 2) Nurses' role in the identification and

timely notification of patient deterioration; 3) Rapid response nurses' role in rounding to help

prevent clinical deterioration before occurring; 4) Utilization of MEWS to decrease IHCA by

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identifying clinical deterioration through the electronic health record (EHR). The findings will be

presented here.

The databases utilized were CINAHL, EBSCOhost, and PubMed, using master and mesh

headings. The following key terms were used in CINAHL: rapid response, MEWS, and in-

hospital cardiac arrests, with 730 potential sources found through different term combinations.

Results were narrowed using peer-reviewed academic journals, limits within the last ten years,

reducing the possible sources to 62 articles. Additional articles were eliminated due to irrelevant

content.

Modified Early Warning Scores

MEWS, a clinical tool used to detect patient deterioration, scores vital signs to predict a

patient's likelihood of intensive care unit (ICU) admission or death within 60 days (MDCalc,

2022). The MEWS tool was developed and is routinely employed to identify patients at risk of

deterioration (MDCalc, 2022). MEWS is used by any healthcare worker that has received proper

training on utilizing and interpreting the results (MDCalc, 2022).  

A controlled pre/post-intervention study published in the International Journal of Nursing

Studies sought to determine if proactive rapid response team rounding can reduce unplanned

escalations in care (Danesh et al., 2018). The background of the study found unanticipated

escalations are seen as a clinician error through delayed or missed acknowledgment of

physiological instability, iatrogenic harm, or ineffective treatment (Danesh et al., 2018). The

study's objective was to examine the impact of an early warning score-based proactive rapid

response team model on the frequency of unplanned escalations in care within the hospital

compared to nurse identification of vital sign derangements (Danesh et al., 2018). The setting

was a 237-bed community hospital with 12,148 adult hospitalized patients as participants during
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a pre/post-intervention period (Danesh et al., 2018). The study found a difference in the

frequency of unplanned escalations in care, with fewer unexpected ICU transfers occurring with

the early warning score proactive rapid response team model (Danesh et al., 2018). 

Emory University School of Medicine implemented MEWS in real-time as part of the

electronic health record (Emory University School of Medicine, 2018). MEWS is an algorithm

utilizing vital signs to compute a score that predicts which patients will decompensate or

deteriorate. MEWS provides an actionable alert system for rapid response teams after validation

from the bedside nurse (Emory University School of Medicine, 2018). An additional layer of

surveillance, skill development for bedside nurses, other eyes on a potentially ill patient, and

prevention of unplanned ICU admissions are all qualities the MEWS application provides

(Emory University School of Medicine, 2018). Heart rate, oxygen saturation, respiratory rate,

blood pressure, urine output, and temperature are all vital sign values in the MEWS calculation

(Emory University School of Medicine, 2018).  

The Department of Medicine at Stony Brook University Hospital completed a study on

low daily MEWS scores as predictors of low-risk hospitalized patients (Mizrahi et al., 2020).

The background of the study includes that MEWS is a well-validated tool used by hospitals to

identify patients at high risk for clinical deterioration (Mizrahi et al., 2020). The study aimed to

determine if a low MEWS score predicts patients with a lower chance of clinical deterioration

(Mizrahi et al., 2020). The study design was a retrospective cohort study including 5,676 patient

days with an analysis of MEWS scores, adverse events, and medical comorbidities (Mizrahi et

al., 2020). The primary outcome was an association of the average daily MEWS scores in

patients with an adverse event compared to the patients who did not have an adverse event

(Mizrahi et al., 2020). Results found patients with an average MEWS >2 were nine times more
16

likely to have an adverse event and 15 times more likely to have an adverse event compared to

the patients with a MEWS of <1 (Mizrahi et al., 2020). MEWS also demonstrated predictive

cardiac arrest and mortality while significantly reducing event incidences by increasing the

number of rapid responses that utilize MEWS, concluding that MEWS enables early intervention

in clinically deteriorating patients (Mizrahi et al., 2020). The study concluded that patients with

MEWS <2 have a significantly lower likelihood of having an adverse event than patients with

MEWS >2 (Mizrahi et al., 2020). 

Donabedian Theoretical Framework 

The theoretical framework used for the DNP project is the Donabedian framework. The

Donabedian framework result indicates what will be measured, reviewed, or evaluated (Moran et

al., 2020). Before and after the implementation of MEWS-based rounding, the number of

MEWS, rapid responses, unplanned ICU transfers, IHCA, survival post-IHCA, and survival to

discharge post-IHCA was compared to determine the outcome. The Donabedian framework

process describes what will be accomplished and how it will be carried out (Moran et al., 2020).

The DNP project process consisted of implementing MEWS-based rapid response rounding for

patients outside of the ICU. The Donabedian framework step that influences the structure

includes the context, where the project implementation will occur, and the secondary de-

identified data collected of patients with a MEWS of four or greater (Moran et al., 2020). The

rapid response nurses, house supervisors, acute care nurses, and the non-ICU patient population

were a part of the DNP project. Among the typical outcome measured by the Donabedian model

are quality improvement projects that reduce mortality (ACT Academy, 2021).
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Methodology

A pre/post observational cohort study design is selected for the quality improvement

DNP project. Cohort studies are observational studies that calculate incidence, cumulative

incidence, prevalence, and incidence rate (Thiese, 2014). A pre/post-study design measures the

occurrence of an outcome before and after the intervention is implemented (Thiese, 2014). The

observation will be of the patients in the medical surgical, medical telemetry, and cardiac

telemetry units from April 2022 through June 2023 to examine the associations between the

outcomes from exposure to the MEWS intervention.   

Setting

The facility where the DNP project took place is a 124-bed acute care hospital with a

Level IV trauma emergency center based in a rural area of metro Atlanta. The hospital is part of

Georgia's most extensive and integrated healthcare system. The facility's mission is to enhance

the health and well-being of every person served. The facility's goal is to deliver world-class

healthcare to every person every time. The facility's values include serving with compassion,

pursuing excellence, and honoring every voice. The unity of the DNP project with the selected

organization's mission and goals align as the DNP project seeks to enhance the health and well-

being of patients by proactively rounding on patients based on their MEWS. The DNP project

stakeholders and the team served with compassion, pursued excellence, and honored every voice

while delivering world-class healthcare every time.

Population

The patient population and sample size consist of the number of elevated MEWS, rapid

responses, IHCA, survival post-IHCA, and survival to discharge post-IHCA while considering

the patient census on the acute care floors at the facility. The project was implemented on the
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medical surgical, medical telemetry, and cardiac telemetry units, each consisting of 28 patient

rooms. The project utilized the three acute care units instead because not every patient had an

elevated MEWS, rapid response, or IHCA. The facility also employed a large float pool staff,

which helped with project consistency throughout the facility. The patient census determined the

unit staffing and included a charge nurse with four to six nurses on each unit. The timeframe for

the DNP project is six weeks.

Inclusion/Exclusion Criteria for the Population

Inclusion criteria for the patient population included patients with a MEWS of four or

above located on the medical-surgical, medical telemetry, and cardiac telemetry floors. The

patients with an IHCA, rapid response, and unplanned transfer to the ICU are also included in the

DNP project. The exclusion criteria for the patient population are patients not on the medical-

surgical, medical telemetry, and cardiac telemetry floors. Other exclusion criteria include

emergency room, intensive care unit, and intermediate care unit patients.

Design

The DNP project's design is a quality improvement project focused on improving the

facility's survival to discharge after IHCA by implementing rapid response rounding on patients

with a MEWS of four or more significant. Quality improvement projects include healthcare

projects that help improve the healthcare for others in the future (Moran, et al., 2020). The DNP

project is considered a quality improvement project based on the evidence that shows the

intervention to improve healthcare for others. A quality improvement project titled, Utilization of

Modified Early Warning Score (MEWS) to decrease in-hospital cardiac arrests (IHCA) is

selected for the DNP project. The desired healthcare outcome of the DNP project will be the

decrease of IHCA with MEWS implementation.

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Data Review Process

The DNP project compared MEWS, IHCA, unplanned ICU transfers, survival after

IHCA, and survival to discharge after IHCA data from before implementing MEWS-based rapid

response rounding to the post-implementation MEWS-based rapid response rounding. The DNP

project data was compared to the AHA and GWTG data to determine if the facility's goal had

increased the survival to discharge after IHCA to 35% to coincide with the goal of the AHA. The

incidence rate calculated consisted of MEWS four or greater, unplanned ICU transfers, IHCA,

survival after IHCA, and survival to discharge per 1,000 occupied patient beds. The facility

inpatient census for the medical-surgical, medical telemetry, and cardiac telemetry floors was

calculated to determine the number of MEWS four or greater, IHCA, survival after IHCA, and

survival to discharge per 1,000 occupied patient beds. The DNP project team leader compared

the data to determine if there was a change.

Risks and Benefits

The benefits associated with the DNP project include improvement in the survival to

discharge rate after IHCA, a decrease in unplanned ICU transfers, and a reduction in IHCA by

implementing MEWS-based rapid response rounding. There are no associated risks with the

DNP project.

Timeline

The duration of the DNP project is from May 2022 to June 2023. In June and July of

2022, the DNP student worked with the administration to develop the project at the facility.

Collaborative Institutional Training Initiative (CITI) Certificate was obtained and attached in

Appendix A. The DNP project received Institutional Review Board (IRB) approval and is
20

attached in Appendix B. Project implementation occurred over six weeks, from May 2023 to

June 2023. The project timeline is included in Appendix C.

In May 2023, the team leader educated acute care nurses and rapid response nurses

during week one of the six-week project. The nurses were educated regarding creating and

adding the MEWS to patient lists, reviewing the MEWS, and interventions in the electronic

health record. The Acute care nurses were educated to notify rapid response if the MEWS was

elevated at four or above. The rapid response nurses were educated on proactively rounding on

patients with elevated MEWS while using the rapid response protocols and notifying the

provider. The team leader created a teaching tool for the nurses during project education and

implementation. The tool contained screenshots from the electronic health record on how to copy

the rapid response patient list created by the team leader. The teaching tool contains hospital data

and is not included in the appendix. The nurses were also provided with detailed information on

MEWS with screenshots from the electronic health record without any patient data attached.

The project implementation phase occurred during the second week of the DNP project

and continued throughout the rest of the project. The nurses reviewed the patients MEWS in the

electronic health record. The rapid response nurses rounded on patients with a MEWS of four or

greater. The next four weeks of the DNP project included continued project implementation. The

number of patients with elevated MEWS, unplanned ICU transfer, rapid responses, IHCA, and

survival to discharge was collected during and at the end of the 6-week project.

Budget and Resources

There was no need for additional financial resources or budget expenses. The facility

already employs the rapid response nurses responsible for rounding on patients with an elevated
21

MEWS. The MEWS tool was included as part of the facility’s electronic health record license

purchased prior to the development of the DNP project.

Evaluation Plan

Statistic Considerations

The DNP project compared MEWS, unplanned ICU transfers, number of rapid response

calls, IHCA, survival after IHCA, and survival to discharge after IHCA data before

implementing MEWS-based rapid response rounding to the post-implementation MEWS-based

rapid response rounding. The DNP project data was compared to the AHA and GWTG data to

determine if the facility's goal had increased to meet the survival to discharge after IHCA to 35%

to coincide with the goal of the American Heart Association. The incidence rate calculated

contained MEWS four or greater, rapid response calls, unplanned ICU transfers, IHCA, survival

after IHCA, and survival to discharge per 1,000 occupied bed days. The facility inpatient census

for the medical-surgical, medical telemetry, and cardiac telemetry was utilized to determine the

occupied bed days. The DNP project team leader compared the data to determine if there was an

increase in the percentage of MEWS utilization and patient survival to discharge post-IHCA and

a decrease in the rate of IHCA.

Data Maintenance and Security

Only secondary de-identified data was collected from the electronic health record. All

secondary de-identified data was collected through the electronic health record reporting

capabilities by the principal investigator and secured on a password-protected computer with

two-factor authorization. The secondary de-identified patient data will be deleted three months

after the completion of the project.

22

The team leader, the only data collector, collected secondary de-identified patient data.

The secondary de-identified data were collected each day before, during, and post-project

implementation. The secondary de-identified data collected included the inpatient census at 0600

hours each day, the number of patients with a MEWS of four or greater, the number of patients

with an IHCA, the number of patients with survival after IHCA and survival to discharge after

IHCA. Secondary de-identified patient data was obtained from the electronic health record by

reviewing the patient lists and reviewing the rapid response reports in the electronic health

record.

Results

Data collection began in April 2022 and continued through the completion of the DNP

project in June 2023. Pre-implementation data included a patient census of 30,979 during the

pre-implementation period from April 2022 through May 2023. During the project

implementation of May 2023 through June 2023, the patient census was 3,999.

There were 968 rapid response calls pre-implementation. There were 117 rapid response

calls post-implementation. Data presented 31.2 rapid responses per 1,000 occupied patient beds

pre-implementation compared to 29 rapid responses per 1,000 occupied patient beds post-

implementation. There were 51 patients with an elevated MEWS of four or greater after project

implementation, with 12.8 MEWS per 1,000 occupied patient beds.

There were 25 IHCAs pre-implementation, and 1 IHCA occurred after project

implementation. There were 0.80 IHCA per 1,000 patient-occupied beds before project

implementation compared to 0.25 IHCA per 1,000 occupied patient beds after implementation.

Of the 25 IHCAs, 20 patients, or 80%, obtained a return of spontaneous circulation (ROSC) and

were transferred to the ICU. Only six patients, or 24%, survived the IHCA and were discharged
23

home pre-implementation of MEWS-based rapid response rounding. Unfortunately, one IHCA

sustained during the MEWS-based rapid response project did not obtain ROSC and did not

survive to discharge.

ICU transfers pre-implementation was 31.2 transfers to ICU after rapid response per

1,000 occupied patient beds. Post-implementation data shows 8.5 transfers to ICU after rapid

response per 1,000 occupied patient beds. The average transfer to ICU after rapid response and

IHCA was 25% before project implementation compared to 20.6% post-implementation.

Results of Data Analysis

The results of the data analysis show that implementing MEWS-based rapid response

rounding is a valuable intervention to decrease the amount of IHCA. MEWS-based rapid

response rounding did increase the number of calls for the rapid response nurses to respond to.

Despite an increase in calls for rapid response nurses, only one patient suffered an IHCA which

improved the rate from 0.80 to 0.25 IHCA per 1,000 occupied patient beds. Patients that

transferred to ICU after a rapid response call also improved from 10.2 transfers to 8.5 transfers

per 1,000 patient-occupied beds. The AHA GWTG goal was not met as the one patient that

suffered a cardiac arrest did not survive to discharge. The data comparisons are listed in

Appendix D.

Discussion

Implications for Clinical Practice

One of the implications for clinical practice is implementing MEWS to reduce IHCA and

improve patients' chance of survival by detecting clinical deterioration before an IHCA occurs.

The DNP project discovered that using MEWS reduces the number of IHCA. According to the
24

DNP project results, MEWS is a useful clinical tool that medical facilities can use to identify

clinical deterioration before an IHCA.

Implications for Quality/Safety

This quality improvement DNP project demonstrated an overall improvement in the

number of patients with IHCA. Implementing MEWS-based rapid response rounding for all

patients with a MEWS score of four or higher will improve the quality of care while maintaining

patient safety. MEWS-based rapid response rounding can be used in all healthcare facilities to

improve the quality and safety of patient care by detecting clinical deterioration before an IHCA.

Implications for Education

MEWS-based rounding by rapid response nurses was shown to decrease IHCA and

improve patient mortality because the amount of IHCA decreases. The DNP project facilitates

the implementation of the MEWS clinical tool in the electronic health record to improve patient

outcomes in any facility. Hospitals can incorporate MEWS education by utilizing nurse

educators, education programs, and unit-based education sessions. Any trained clinician can use

MEWS.

Limitations

Numerous factors constrain the DNP project. Although MEWS is a helpful clinical tool

for rapid response nurses, it is based on clinical data recorded in the patient's chart. If the

patient's acuity is low, a MEWS may not be elevated for every patient, resulting in a small

number of patients with an elevated MEWS. The implementation of Epic's deterioration index is

an added project constraint. The deterioration index (DI) score incorporates many additional

patient-related factors. MEWS consists of fewer variables than DI. Like the MEWS method, the

rapid response nurses conduct rounds on patients with high scores.

25

Dissemination

Posters, presentations, and papers have been utilized to disseminate the findings of the quality

improvement DNP project. The DNP project was presented at the University's virtual project

dissemination day with a poster and brief presentation. The DNP manuscript will be accessible

through the Public Repository system of the JSU Library.

Sustainability

The DNP project implementation did not end at the facility upon project completion. The

MEWS application remains accessible within the electronic health record. The MEWS-based

rounding procedure is still in effect in the hospital's medical inpatient units. Through

dissemination, other inpatient hospital units are anticipated to implement rounding based on

MEWS.

Plans for Future Scholarship

Although the DNP project did not reveal improved patient mortality following IHCA,

additional research is still necessary. MEWS is a valuable clinical tool for rapid response nurses;

however, additional investigation is required to assess how much MEWS improved the IHCA

rate. It is also essential to further investigate, given that the hospital also implemented DI-based

rounding by rapid response nurses. DI is a comparable early warning tool to MEWS, utilizing

more factors than the MEWS tool. Since the data was collected after six weeks, further research

can also examine the longevity of implementing the MEWS-based rapid response rounding.

Conclusion

In the United States, cardiac arrests cause about 300,000 to 450,000 deaths each year

(National Institute of Health, 2022). There were 22.4% of 33,874 adults with pulseless in-

hospital cardiac arrests at 328 hospitals whose patients survived to hospital discharge, according
26

to data from GWTG 2020 (Tsao, 2022). At hospital discharge, 79.5% of survivors had good

functional status (Cerebral Performance Category 1 or 2) (Tsao, 2022). This prompted the AHA

GWTG to raise the survival to discharge goal after an IHCA to 35% (Tsao, 2022).

Before nursing and medical staff recognize and respond to changes in vital signs, the

condition of patients may deteriorate (Flenady et al., 2017). Patients at risk for clinical

deterioration frequently exhibit alterations in vital signs up to twenty-four hours before a critical

event (Huff et al., 2018). MEWS has shown efficacy in identifying patients at risk for clinical

deterioration and improving patient outcomes (Huff et al., 2018). The DNP project aimed to

meet the AHA GWTG of 35% survival to discharge after IHCA by implementing MEWS-based

rapid response rounding.

The DNP project revealed the facility did not meet the AHA GWTG goal of 35%

survival to discharge after IHCA. The optimal method for improving survival to discharge and

reducing IHCA should be determined through additional investigation. This DNP project and

similar studies will continue to improve patient outcomes.

27

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Appendix A

Collaborative Institutional Training Initiative Certificate

32

Appendix B

Institutional Review Board Approval

33

Appendix C

Project Timeline

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

Task 1 Team May 8-
Development May 14

Task 2 Plan May 8-

Development May 14
Task 3 Rapid May 8-
Response May 14
Education
Task 4 May 8-
Acute Care May 14
Nurse Education

Task 5 May 15- May 22- May 29- June 5- June 12-
MEWS List May 21 May 28 June 4 June 11 June 18
Construction and
Go Live
Task 6 June 19
Project
Completion/Data
Completion
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Appendix D

Data Comparison Graph

35 31.2
29
30
25
20
12.8
15 10.2 8.5
10
5 0.8 0.25 0
0
IHCA Rapid Response ICU Transfers MEWS

Pre-Implementation Post-Implementation