Christiana Care Early Warning System goes Live at Christiana Care

The Christiana Care Early Warning System (CEWS), a standardized measure of patient acuity that will help proactively identify patients who are deteriorating physiologically and support timely care and improved outcomes, was introduced to clinical practice in select units in May 2017.

The introduction, in which the early warning system is being displayed in five inpatient units at Christiana and Wilmington Hospitals to trigger real-time alerts for at-risk patients, is a key step in the ongoing, iterative development of CEWS. The alerts will give care providers relevant information about patients’ current CEWS values, including 24-hour score trends, as well as clinical recommendations. For example, CEWS could recommend more frequent vital-sign monitoring or activation of a Rapid Response Team should a patient have a concerning score or rapid change in score.

The Value Institute is developing CEWS in collaboration with Nursing and the Office of Quality and Patient Safety. The system couples an electronic health records-based predictive algorithm with electronic Nurse Screening Assessments that collect nurses’ first-hand observations, beyond vital signs, that may be indicative of a patient’s health to identify declining patients earlier and more reliably.

Phased implementation of the system began with a four-unit pilot in early 2015, and then was expanded to 26 units in December 2016. CEWS values were not displayed to providers, nor were alerts or clinical interventions offered, in either phase.

A major focus prior to incorporating live alerts was researching how to balance factors such as alert frequency and timeliness to ensure alerts maintain their effectiveness. A multidisciplinary team of clinicians, health information technology experts, industrial engineers and human factors experts assessed this issue by developing and evaluating three different alert frameworks. Each framework has two components: a set of criteria for triggering an alert and a set of “blocking rules” to mute alerts when certain criteria are satisfied for a pre-determined time window.

The team evaluated three alerting strategies – conservative, intermediate and liberal – using retrospective data derived from five Christiana Care units to compare the number of alerts generated and the opportunity of early recognition of clinical deterioration at a unit and individual patient level. This allowed the team to select the alerting strategy being implemented in May, which best balances early detection and appropriate alerting frequency.