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      Monitoring Vital Signs: Development of a Modified Early Warning Scoring (Mews) System for General Wards in a Developing Country

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          Abstract

          Objective

          The aim of the study was to develop and validate, by consensus, the construct and content of an observations chart for nurses incorporating a modified early warning scoring (MEWS) system for physiological parameters to be used for bedside monitoring on general wards in a public hospital in South Africa.

          Methods

          Delphi and modified face-to-face nominal group consensus methods were used to develop and validate a prototype observations chart that incorporated an existing UK MEWS. This informed the development of the Cape Town ward MEWS chart.

          Participants

          One specialist anaesthesiologist, one emergency medicine specialist, two critical care nurses and eight senior ward nurses with expertise in bedside monitoring (N = 12) were purposively sampled for consensus development of the MEWS. One general surgeon declined and one neurosurgeon replaced the emergency medicine specialist in the final round.

          Results

          Five consensus rounds achieved ≥70% agreement for cut points in five of seven physiological parameters respiratory and heart rates, systolic BP, temperature and urine output. For conscious level and oxygen saturation a relaxed rule of <70% agreement was applied. A reporting algorithm was established and incorporated in the MEWS chart representing decision rules determining the degree of urgency. Parameters and cut points differed from those in MEWS used in developed countries.

          Conclusions

          A MEWS for developing countries should record at least seven parameters. Experts from developing countries are best placed to stipulate cut points in physiological parameters. Further research is needed to explore the ability of the MEWS chart to identify physiological and clinical deterioration.

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          Most cited references30

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          Clinical antecedents to in-hospital cardiopulmonary arrest.

          While the outcome of in-hospital cardiopulmonary arrest has been studied extensively, the clinical antecedents of arrest are less well defined. We studied a group of consecutive general hospital ward patients developing cardiopulmonary arrest. Prospectively determined definitions of underlying pathophysiology, severity of underlying disease, patient complaints, and clinical observations were used to determine common clinical features. Sixty-four patients arrested 161 +/- 26 hours following hospital admission. Pathophysiologic alterations preceding arrest were classified as respiratory in 24 patients (38 percent), metabolic in 7 (11 percent), cardiac in 6 (9 percent), neurologic in 4 (6 percent), multiple in 17 (27 percent), and unclassified in 6 (9 percent). Patients with multiple disturbances had mainly respiratory (39 percent) and metabolic (44 percent) disorders. Fifty-four patients (84 percent) had documented observations of clinical deterioration or new complaints within eight hours of arrest. Seventy percent of all patients had either deterioration of respiratory or mental function observed during this time. Routine laboratory tests obtained before arrest showed no consistent abnormalities, but vital signs showed a mean respiratory rate of 29 +/- 1 breaths per minute. The prognoses of patients' underlying diseases were classified as ultimately fatal in 26 (41 percent), nonfatal in 23 (36 percent), and rapidly fatal in 15 (23 percent). Five patients (8 percent) survived to hospital discharge. Patients developing arrest on the general hospital ward services have predominantly respiratory and metabolic derangements immediately preceding their arrests. Their underlying diseases are generally not rapidly fatal. Arrest is frequently preceded by a clinical deterioration involving either respiratory or mental function. These features and the high mortality associated with arrest suggest that efforts to predict and prevent arrest might prove beneficial.
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            The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study.

            The Modified Early Warning Score (MEWS) is a simple, physiological score that may allow improvement in the quality and safety of management provided to surgical ward patients. The primary purpose is to prevent delay in intervention or transfer of critically ill patients. 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. Fifty-seven (17%) ward patients triggered the call-out algorithm by scoring four or more on MEWS. Emergency patients were more likely to trigger the system than elective patients. Sixteen (5% of the total) patients were admitted to the ITU or HDU. MEWS with a threshold of four or more was 75% sensitive and 83% specific for patients who required transfer to ITU or HDU. 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.
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              A prospective before-and-after trial of a medical emergency team.

              To determine the effect on cardiac arrests and overall hospital mortality of an intensive care-based medical emergency team. Prospective before-and-after trial in a tertiary referral hospital. Consecutive patients admitted to hospital during a 4-month "before" period (May-August 1999) (n = 21 090) and a 4-month intervention period (November 2000 -February 2001) (n = 20 921). Number of cardiac arrests, number of patients dying after cardiac arrest, number of postcardiac-arrest bed-days and overall number of in-hospital deaths. There were 63 cardiac arrests in the "before" period and 22 in the intervention period (relative risk reduction, RRR: 65%; P < 0.001). Thirty-seven deaths were attributed to cardiac arrests in the "before" period and 16 in the intervention period (RRR: 56%; P = 0.005). Survivors of cardiac arrest in the "before" period required 163 ICU bed-days versus 33 in the intervention period (RRR: 80%; P < 0.001), and 1353 hospital bed-days versus 159 in the intervention period (RRR: 88%; P < 0.001). There were 302 deaths in the "before" period and 222 in the intervention period (RRR: 26%; P = 0.004). The incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based medical emergency team.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                24 January 2014
                : 9
                : 1
                : e87073
                Affiliations
                [1 ]Division of Nursing and Midwifery, Department of Health & Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa
                [2 ]Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa
                [3 ]Department of Anaesthesiology, Groote Schuur Hospital/University of Cape Town, South Africa
                [4 ]School of Human and Health Sciences, Swansea University, Wales, United Kingdom
                D’or Institute of Research and Education, Brazil
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: UK. Performed the experiments: UK. Analyzed the data: UK JJ MJ SJ. Wrote the paper: UK SJ MJ JJ.

                Article
                PONE-D-13-41862
                10.1371/journal.pone.0087073
                3901724
                24475226
                cda96d23-1f6a-4035-96ef-6435d18e2c5d
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 19 July 2013
                : 23 December 2013
                Page count
                Pages: 10
                Funding
                This work was supported by the University of Cape Town Research Development Fund and the Faculty of Health Sciences Research Committee. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Mathematics
                Applied Mathematics
                Algorithms
                Medicine
                Anatomy and Physiology
                Physiological Processes
                Homeostasis
                Non-Clinical Medicine
                Health Care Policy
                Quality of Care
                Health Care Providers
                Health Care Quality
                Nursing Science
                Nursing Education

                Uncategorized
                Uncategorized

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