Innovative algorithm saves lives: instant alerts to changes in patients' vital signs

“Code Blue,” a phrase many hospital staff hear daily, generally means a patient has gone into cardiac arrest. It sends response teams rushing to provide emergency resuscitation.

For patients and their families, Code Blues are traumatic—and the unfortunate reality is the majority of hospital patients who experience one do not survive. For physicians and hospitals, they are not only distressing, but also frustrating; more patients would recover if their deteriorating vital signs were recognized and addressed sooner.

Rapid response teams

To address this issue, about a decade ago, the Ontario Ministry of Health and Long-term Care introduced rapid response teams—groups of critical care nurses and physicians who rush to intervene when patients deteriorate. Alison Fox-Robichaud, an associate professor in the Department of Medicine at McMaster University, and critical care physician with Hamilton Health Sciences, found that the concept was effective, but didn't go far enough: Code Blue rates dropped, but not substantially.

Although early warning systems have been in place for many years, almost all of them are paper based. Fox-Robichaud started developing a customized electronic early warning score based on patients' vital signs and indicators. The result of her research, the Hamilton Early Warning Score (HEWS), measures the abnormality of patients' health signs; a score of six or higher results in an immediate call to a rapid response team.

Christine Probst, Director of Informatics, Hamilton Health SciencesDr. Fox Robichaud partnered with Christine Probst, Director of Informatics at Hamilton Health Sciences early in the process to include electronic documentation of HEWS vitals signs into the Meditech Hospital Information system. With the support of clinical leadership, HEWS was implemented across the Hamilton General Hospital and the Juravinski Hospital, with bedside nurses measuring and entering vital signs data into the HIS. There was added value in programming the HEWS algorithm into the clinical documentation system with the ability to automatically calculate the HEWS score, and prompt the nurse if care needed to be escalated.

HEWS and the electronic warning scores were a significant improvement, but a challenge remained. Notes on vital signs were often written on paper first, only to be entered into a computer hours later, when nurses found the time. Fox-Robichaud and Probst wanted to reduce potential delay in electronic documentation of vitals signs and automate the alerts to the rapid response team. They felt this could be best accomplished by using a smartphone app, making the entire scoring system electronic.

Finding a partner

Hamilton Early Warning Score (HEWS) Handheld.

With funding from Hamilton Health Sciences, Probst and Fox-Robichaud teamed up with IBM Canada and the Toronto-based ThoughtWire Corp. to create a the HEWS Handheld platform using Thoughtwire's Ambiant Technology. The result was the HEWS Handheld, the first in Canada, that reduces the potential lag time between when vital signs are observed and warnings are issued and automatically notifies care providers when escalations of care are required.

Today, the original HEWS is in use throughout the acute care adult population of Hamilton Health Sciences while the HEWS Handheld is being piloted in one ward. The next step will be to extend it to all adult and pediatrics inpatient units. The team is also working on introducing the HEWS into pre-hospital care.


From “Code Blue” to “Code Clear”

When Fox-Robichaud first began looking at ways to reduce Code Blue calls in 2006, Hamilton General had nearly 400 per year, a typical number for a hospital of its size. Thanks to HEWS, the number was just 54 in 2016. With HEWS Handheld, she expects it to drop even more. “Nowadays, everybody's ears perk up when they hear a Code Blue in a ward, because it's such a rare event compared with before.”

Homegrown talent

Being located in Ontario helped her innovation succeed, says Fox-Robichaud: ThoughtWire is Ontario-based, and McMaster University offered valuable collaborative support, including statistical help and a health research methodology program for technology assessment.

Grad students and residents are studying ways to improve the technology, including making it more patient-centric.

The access to talent within [McMaster University] was pivotal. We were able to bring in specialized researchers to study the process and communication around vital signs.

Fox-Robichaud says she was also lucky that Hamilton Health Sciences is a research-intensive hospital that made sure she had the funds to study the technology properly. “I'm a scientist at heart—how else can I prove to the rest of the world that this is important?”

Hamilton Health Sciences (HHS) Logo.

The drive to save more lives

In addition to the potential opportunities for research and product development, there are certainly opportunities for partnership, says Fox-Robichaud. Sharing this technology with interested organizations and other healthcare jurisdictions that have similar requirements is definitely an option because, at the end of the day, what's good for patients is good for the health care system, Probst points out. “If we can identify and respond to patients who are deteriorating earlier, we can avoid costly and invasive treatment.”

Probst and Fox-Robichaud envision sharing the technology with hospitals across Canada and beyond, in the long term. “It started a conversation across the country,” says Fox-Robichaud. “We need to keep that momentum going.”