Clinical Transformation
and Education
Safer Wards
Catharina Hospital
cuts average length of stay
for patients readmitted to ICU by 41% with the aid of Philips clinical
transformation capabilities
Key improvements
• 41% reduction in average
length of hospital stay
for patients readmitted
to the ICU – reduces
time spent in medium
and intensive care units,
prevents overflows and
medical costs all the way
up the line
• Reduced time for taking
vital signs from 15 minutes
to 5 minutes
• Nurses see a clear
overview of deteriorating
patients on their monitors
• Majority of nurses feel
that patient care has
improved due to EWS
practices
As an early adopter of early warning score
(EWS) best practices on patient wards, the
Catharina Hospital carried out the first European
Safer Wards implementation, leveraging
Philips IntelliVue Guardian Solution. For this
project, Philips consultants in transformation
and education helped the hospital implement
and manage an effective track-and-trigger
monitoring system for their new Step Forward
Unit (SFU). At the end of the project, data
showed a 41% reduction in the average hospital
stay for patients readmitted to the ICU.
During discussions between the hospital’s key EWS
stakeholders and the local Philips team, both parties
saw an opportunity to use the hospital’s new high
dependency Step Forward Unit to collaboratively
explore and implement the usage of a digital early
warning score solution to help improve patient care
and workflow, as well as communication between
nursing staff and physicians.
The harsh reality
Hospitals – the very places where we go to get well –
may not be as safe as we think. High workloads and
reduced staffing on the general floor can make it very
difficult to predict which patients to watch more closely.
In fact, 40% of unanticipated deaths in hospitals occur
on the general ward.1 Can these deaths be prevented?
How?
Prof. Dr. Erik Korsten,anesthesiologist-intensivist
The Catharina Hospital in Eindhoven, the Netherlands
is one of the leading teaching hospitals in the country
with 30 medical specialties and 500,000 patient
admissions per year. The hospital is known for providing
excellent care to patients with routine illnesses, as well
as complex cancer, heart, and vascular diseases.
In addition, it carries out a broad range of scientific
research that is highly regarded in the international
medical community.
Step Forward Unit (SFU)
• General patient ward
• Focuses on major surgery patients who come
to the SFU after a quick stay in the ICU
• Patients require vital sign collection four times
during a 24 hour period
• The hospital had just started implementing
a paper-based EWS system but decided to pilot
an automated EWS system on the SFU
Managing hospitals within hospitals
More severely ill patients on general wards
Like many healthcare facilities, Catharina Hospital
is taking care of more severely ill patients on their
medium and general care wards. Prof. Dr. Erik Korsten,
anesthesiologist-intensivist at Catharina Hospital
provides an example. “The severity of this problem really
came home for me when I was called in one evening as
part of the Rapid Response Team to decide whether a
patient in the general ward should be moved to the ICU.
I was supposed to check one patient, but there were two
other patients lying next to him, and I thought ‘I should
take all three of them.’ I knew if we didn’t move them
then, they would probably have to go to the ICU the next
day because they were in such poor condition.”
Drive for improvement
As medium and general care wards become hospitals
within hospitals, one of the greatest challenges for care
facilities such as the Catharina Hospital is to provide
better and more patient-focused care, while keeping the
costs manageable. Catharina Hospital has a relentless
drive to evolve its processes and technologies to improve
patient safety and the quality of care. They were one of
the first to adopt the practices surrounding Modified Early
Warning Scores (MEWS) in Europe, meaning they could
select additional parameters to modify their monitoring
parameters depending on their specific need.
Prof. Dr. Korsten says, “I also participated in a remote
monitoring project subsidized by the European
Commission (Recap). So this was a perfect fit.”
The warning signs are there
Clinical instability is present and measurable prior to
patient decline. Research carried out in several countries
showed that 15-20% of hospitalized patients develop
serious adverse events.2, 3, 4 Up to 80% of adverse events
are preceded by abnormal signs and symptoms that
occur several hours and sometimes days beforehand.5, 6
In fact, warning signs of physiological decline typically
appear six to eight hours prior to an event. If these signs
are not recognized and acted upon, further deterioration
can occur. Data from the Netherlands show an identical
picture, and over 1,735 patients die annually of potentially
avoidable causes.7
Research suggests that 70% (45/64) of patients show
evidence of respiratory deterioration within eight hours
of cardiac arrest.6 In two-thirds of cases (99/150), patients
show abnormal signs and symptoms within six hours of
arrest, while an MD is notified only 25% of the time
(25/99).5
Despite these findings, not all hospitals take a systematic
approach to identifying, communicating, and rapidly
treating such patients. One study8 showed that the
complete set of critical vital signs were taken for only 15%
of patients in the general ward for the first three days
after surgery:
• RR missing in 15.4%
• HR missing in 4.2%
• BP missing in 5.5%
• Sat missing in 6.7%
• Nurse notes missing in 5.5%
What goes wrong on general wards?
Three main issues contribute to the problem
of addressing deteriorating patients:
• Failures in planning (including assessments,
treatments, and goals)
• Failure to communicate (patient-to-nurse,
nurse-to-nurse, nurse-to-physician, etc.)
• Failure to recognize deteriorating patient condition9
“Monitoring must be simple, smart,
and must advise.”
A
B
C
Philips Safer Wards program
Philips has a long history of working with healthcare
facilities to help them improve their clinical processes
and care environment. Philips clinical delivery consultants
provide objective data and analysis along with change
management support to help healthcare facilities
improve patient safety through the effective
implementation of a customized EWS.
A and B: these pods measure different vital signs and wirelessly transmit them to the GuardianSoftware.
C: The GuardianSoftware automatically calculates the MEWS score, shown here in red (score of 8) on the monitor.
Value of an external consultant
Change is a necessity in today’s fast-paced healthcare
environment, but the fact is that most change
management programs fail. In a survey of business
executives from around the world by McKinsey &
Company, only 30 percent of them considered their
change programs completely or mostly successful.10
Another study reports the number of successful change
management projects are even lower at 25 percent.11
Working with an external consultant on such projects can
greatly increase the chances of success.
Advantages of automated EWS
Philips IntelliVue Guardian Solution
Philips clinical delivery consultants then implemented
the IntelliVue Guardian Solution which provides a trackand-trigger system in the Step Forward Unit. Caregivers
use wireless measurement pods to take non-invasive
blood pressure (NBP), heart rate, and pulse oximetry
(Sp02) rates, which are automatically sent to the Guardian
Software. Other parameters are entered manually:
urine output, AVPU, temperature, and the nurse’s level
of concern.
Janine Clevers, team lead general ward
A new approach to monitoring
A step forward in care
Frank Blom, head nurse in the general ward says,
“We created the Step Forward Unit as a separate
general patient ward to provide a step forward in care
for seriously ill patients we were getting from the ICU.
Many of these patients have had major surgery, and are
still very sick when they get to this ward and we wanted
a structured way of monitoring their condition.”
This required a new approach to monitoring according to
Prof. Dr. Korsten. “Monitoring in general wards cannot be
continuous and cannot send alarms. Monitoring in these
areas must be simple, smart, and must advise. Our goal
was to implement EWS practices on a general ward that
would: facilitate vital signs collection, prompt caregivers
to complete data sets, assess risk, and advise. We then
wanted to study how this might affect patient care and
the nursing workload.” In collaboration with Philips,
Catharina SFU team decided to measure the number of
readmissions to the ICU, number of ICU deaths, ICU
length of stay (LOS), and hospital LOS for those patients
who were readmitted to the ICU.
How does your facility rate in handling patient
deterioration?
1. How do you currently monitor and track patient
deterioration in your general wards?
2.How effective are your current efforts to reduce
preventable deaths and unplanned ICU admissions?
3.Who should be contacted if there is a clinical
problem with a patient and how long does it take
for that person to arrive?
4.How do your current patient deterioration
management strategies compare to Evidence Based
Practices (EBP) and Best Practice Guidelines (BPG)?
5.Have you been able to identify the areas in your
current workflow/processes that will measureably
improve how patient deterioration is managed?
Automating the MEWS calculation was a big
improvement for nursing staff. Janine Clevers, general
ward team lead says, “We used to enter the vital signs
and calculate the MEWS manually, and it is simply
impossible to do this in a consistent way for a number
of patients.” After the IntelliVue Guardian Solution was
installed, Philips provided intensive training on using the
monitors and wireless equipment for nurses and
physicians on the Step Forward Unit. “They trained us
so we could take the vital signs in just five minutes,”
says Clevers.
The MEWS is displayed on a central monitor at a nurse’s
station in the hall. For the Catharina Hospital, a MEWS
score of 2 sends an “observe” message and a MEWS
score of above 3 sends an “urgent” message. The trends
can also be displayed over various times. The team set up
a protocol for the entire workflow. When an “urgent”
message is displayed, the Rapid Response Team is
informed for early, effective intervention.
An example of the overview of patients on the Step
Forward Unit shown on the IntelliVue Guardian monitor.
The red numbers are “urgent” messages.
“They trained us so we
could take the vital signs
in just five minutes.”
“The advantage of
the GuardianSoftware
is its Big Data. We
could use information
from over 20,000
patients to benchmark
our own data.”
Post-project staff survey is very positive
After the project Philips conducted a staff perception
survey and 71% of the SFU nursing staff participated.
Key survey results:
• Patients get help quickly and effectively due
to the new EWS practices
• Nurses feel supported by the medical staff
and management
• EWS practices allow nursing staff to provide better
care to their patients
• 78% of the respondents agreed that patient care
has improved due to the EWS practices
Final results – reduced hospital stay for patients
readmitted to ICU by 41% and improved staff adherence
to EWS protocols
“This is the new world. If you see what information
you can get, it’s fantastic,” says Blom. “You have to dare
to stick your neck out and change how you do things,
but it’s worth it.”
Data guides the change process
You can only change what you can measure
The team made several important findings based on the
data provided. Clevers says, “When we started looking at
the data, we saw that the information was there but there
was no escalation. We also were not doing a MEWS as
part of our standard protocol so we were often getting
the score too late.”
After discussion with physicians, the project team
decided to take vital signs four times a day at set times
instead of just three times a day at random times. “Now
you pick up the signs that a patient is worsening, sooner,
so we can readmit them to ICU, sooner, so they can get
better more quickly,” says Clevers. “By using this system,
we expected to see a reduction in readmissions to the
ICU, but instead we have seen that we are sending less
sick patients back to ICU, so their overall hospital stay
is shorter.”
Blom says, “the advantage of the Guardian Software is
its Big Data. We could use information from over 20,000
patients to benchmark our own data and adapt it to our
needs.” The team changed the weighting of certain
variables based on the data analysis performed by
Philips. The data showed that respiration is always the
first parameter to change as a patient’s condition
worsens, so this has been given more priority. The level
of nurse’s concern has also been given more importance
because the nurse is in close contact with the patient
over long periods and their observations are usually
very accurate.
In the beginning, the adherence to the EWS protocols
was only 66%. One suggestion that Philips made to
improve this was to appoint two Super Users on the Step
“Most facilities that are using EWS systems are focusing
on reducing patient mortality, which is of course
important, but after doing this project we realized that is
the wrong starting point. A better starting point is to focus
on reducing the overall patient stay. That’s what gives
you a much better chance in the end of reducing patient
mortality,” says Prof. Dr. Korsten.
“For these six beds (SFU), we reduced the average length
of hospital stay for patients readmitted to the ICU by an
average of 41%,* compared to the nine months before the
EWS implementation. That has a huge impact on patient
welfare,” adds Prof. Dr. Korsten. “Studies have shown that
the detrimental effects on patients who have a lengthy
hospital stay can be seen as much as a year afterwards.
This reduction has an enormous effect across our entire
chain of care. It reduces time spent in our medium care
unit and our ICU unit, preventing overflows and medical
costs all the way up the line.”
Frank Blom, head nurse general ward
Forward Unit to help support and train the other nurses
on the unit in using the IntelliVue Guardian Solution.
Clevers says, “The Super Users were important for setting
an example of adhering to the protocols and encouraging
other nurses to do that as well.” By the end of the project,
92% of the patients on the Step Forward Unit were being
scored according to the EWS protocol. Plus, action was
taken on an EWS score above 3 in 80% of the cases.
Tremendous improvement for staff
“When you are working the night shift, and you have your
monitor with a clear view of what’s going on with the
patients you feel a lot more relaxed and in control of the
situation,” says Blom.
“This reduction has an enormous effect across
our entire chain of care. It reduces time spent
in our medium care unit and our ICU unit,
preventing overflows and medical costs all
the way up the line.”
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
We have complex and sick patients on our ward.
Patients get help quickly and effectively due to our EWS practice.
Our EWS practice gives me confidence to escalate the care.
The work environment provides a sense of support and security for junior medical and nursing staff.
Clevers adds, “This system has helped us improve
the quality of our care enormously on the general ward.
We always thought that ICU and medium care were the
most critical wards, but now we see that it’s actually the
general wards where you want to have the best possible
monitoring. That’s also the biggest group of patients so
it’s logical to focus your attention there.”
Due to our EWS practice I am able to ask for help if I am concerned about the patient.
When my patient is sick, I discuss it with my colleague before I escalate the care.
If I can’t reach the doctor I call the SIT team.
I am reluctant to escalate care because I am afraid to get criticized if the patient is not as sick as I presumed.
If the vital signs are normal but I am concerned about the patient condition I will escalate care following the EWS protocol.
If the patient has a high EWS score but is not ill, I will not call a doctor.
Doctors support my choice to call them as a result of our EWS practice.
Disagree
Do not know
Agree
The other nurses on the unit support my choice to call a doctor in as a result of our EWS practice.
The team leaders on the unit support my choice to call a doctor as a result of our EWS practice. Score.
Due to our EWS practice I have a higher workload if I am taking care of a sick patient.
I understand my role as part of our EWS practice.
“I think the most important result is that patients feel
safer on the ward and nurses feel safer as well. Now we
can quickly see when a patient is crossing the border into
the danger zone, and that gives us a tremendous feeling
of support. We feel much more confident as we go about
our work.”
Fully disagree
Due to our EWS practice my clinical skills will diminish.
Our EWS practice allows me to provide better care to patients on my unit.
The doctors react, in accordance to our EWS protocol.
Our EWS allows for more effective collaboration.
The SIT team effectively communicates and provides me with timely feed-back.
I know what to do with the patent when the SIT team has been called.
Do you think the implementation of safer wards program improved patient care?
Do you think the implementation of safer wards program made this a better place to work for nurses?
I received adequate amount of training to effectively adhere to the new EWS practice.
* Results are based on six beds so they are not statistically significant.
Fully agree
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