Tokushukai will introduce Japan's first EMR-integrated early warning system for detecting sudden deterioration in patients, aiming to minimise the risk of severe illness and death. Initial deployment is planned for September at Chubu Tokushukai Hospital in Okinawa, followed by Shonan Kamakura General Hospital in Kanagawa. The system will then be introduced at other hospitals and is expected to make a substantial contribution to survival after in-hospital deterioration.

The system was developed to detect deterioration early and save lives, addressing the rare cases in which apparently stable inpatients suddenly worsen and die before treatment can be given.

Tokushukai's system draws on the first such system developed in Australia and a refined version used in the United Kingdom. Adoption in Japan has lagged behind. Tokushukai began development in 2010 and aims to launch Japan's first operational system in September.

Following implementation in Australia, unexpected cardiopulmonary arrest among inpatients fell from 0.4% to 0.2%. In the United Kingdom, in-hospital mortality in intensive care units (ICUs) improved significantly, from 22.7% to 14.7%. These results have led to adoption in Europe and North America, and early warning systems are becoming a global standard.

The system scores vital signs, level of consciousness and other observations. When the score reaches an alert threshold, an audible alarm and an on-screen EMR message notify staff, as shown in the diagram. An alert triggers an immediate call to a doctor.

Tokushukai has included nurses' intuition, or “sixth sense”, among the warning criteria: the feeling that a patient is not their usual self or that something is wrong. This criterion is also used in Australia and reflects the value Tokushukai places on the judgement of nurses, who spend considerable time with patients.

Katsuhiko Ozaki, President of Tokushukai Information System, Inc. (TIS), which developed the system, explains: “We can add patterns based on patients' age or clinical specialty and change the warning score thresholds. This allows each hospital to operate the system according to its size, local circumstances and specialties.” Developing the system in-house has made it highly adaptable.

Nurses are essential to detecting deterioration

Nurses who measure vital signs during rounds and at other times will operate the system in practice. Its purpose is to ensure that deterioration is not missed, something nurses already pay particular attention to in their daily work.

New nurses, however, may not always recognise warning signs. By scoring vital signs and other observations, the system helps prevent missed signs, supports new nurses and provides opportunities to learn when deterioration may occur.

Early detection alone is not enough if there are no nurses able to support the response. ICU nurses and ward team leaders currently fulfil this role, but more nurses with the skills to respond appropriately are needed.

Chizuru Yusa, who oversees nursing at Tokushukai Group headquarters, emphasises: “The most important challenge in operating this system is developing nurses who can make sound judgements in emergencies.”

Tokushukai encourages nurses to qualify as certified nurses in intensive care or emergency nursing and to take TCLS, Tokushukai's advanced life support course, to increase the number able to respond to emergencies.

Yusa adds: “In the future, we would like to establish a dedicated multidisciplinary liaison team for the early warning system, as in Australia and the UK, improving nursing quality and making patients even safer.”

Different scoring methods at the first two hospitals

An alert requiring a doctor to be called is issued when monitored values exceed specified limits. However, Chubu and Kamakura hospitals will use substantially different approaches to scoring the warning criteria before an alert is issued.

Chubu Tokushukai Hospital: alerts based on the total score

At Chubu, the risk level rises when the combined score of the monitored values exceeds a set threshold, as shown in the table. Lists of patients in three risk categories can be viewed in the EMR, and staff respond according to an algorithm.

Eriko Ue, the head nurse responsible for implementation, explains how the system helps bridge differences in experience: “This scale for assessing urgency makes it easier for new nurses to understand a patient's condition.”

Listing patients at risk of becoming seriously ill helps staff use their time effectively. Early intervention may also reduce ICU transfers, an important consideration at a hospital with few available ICU beds.

Nurses also plan to listen to care workers and family members and incorporate their observations into the “sixth sense” score. Involving more observers is intended to help prevent patients from becoming seriously ill.

Shonan Kamakura General Hospital: a single criterion can trigger an alert

At Kamakura, an alert is issued if even one warning criterion falls outside its specified range. To keep operation simple, the system deliberately does not assess non-alert states, and its algorithm consists only of calling a doctor. Its success therefore depends on how quickly staff respond to alerts.

“If doctors properly understand the system's importance, nurses can convey an emergency simply by saying, ‘The early warning system has issued an alert,’” says Yusa.

One advantage is that nurses can call a doctor during deterioration without hesitating over whether their judgement is correct. To make the most of this, nurses and doctors have held repeated meetings on operation of the system. The hospital intends to strengthen their cooperation further before launch.

Yusa says: “We want to demonstrate the system's value by showing how it improves patient survival and other outcomes.”

Source: Tokushukai Newspaper, 2 July 2012, No. 832