Marjon Borgert

26 Chapter 2 METHODS Study design A quasi-experimental study was conducted from the 1st of September to the 31st of November 2011 in a University Hospital in Amsterdam, the Netherlands. We implemented a RRS on 18 adult general wards. Ten wards were randomized to the protocolized arm to measure the MEWS minimal three times daily and eight to the control arm, i.e. MEWS measurements when clinically indicated. Randomization was performed after strati cation according to surgical or medical ward. Patients with at least one overnight stay were included. Components of RRS Sta on the intervention (protocol) wards performed a full set of vital signs including a MEWS at least three times daily. Sta on the control wards performed vital signs when judged to be clinically indicated. In both groups, the RRS algorithm (Fig. 1) stipulated that upon reaching a MEWS of 3 points or more (‘critical MEWS’), the patients’ physician should be noti ed by the nurse. In accordance with the ‘two-tiered’ Dutch protocol the patients’ primary physicians were instructed to attend to their patients within 30 minutes, perform an assessment and initiate treatment. The physicians’ intervention could include activation of the RRT. If the patient did not improve after the primary intervention or if the physician was unable to assess the patient, the RRT had to be noti ed. The RRT operated 24/7 and consisted of an ICU physician and nurse who attended the patient within 10 minutes after noti cation. Implementation process Implementation of the RRS started in June 2011. Per ward three nurses were trained. Using a ‘training the trainers’ concept, these nurses educated their colleagues from June until August 2011. There were separate sessions for physicians during hand-over meetings. The RRS algorithm was distributed on pocket cards and advertised with posters, emails to sta and on the local website. From the 1st of September, the RRS was o cially in use. De nitions Clinically indicated measurement of the MEWS was de ned as when regular vital sign measurements led to a MEWS-sub score of 1 or more, this required the complete set of measurements to be calculated (Supplementary File 1). MEWS-sub scores refer to the MEWS applied to a single vital sign. The term ‘MEWS’ is used for the summation of all (available) sub scores. A MEWS of three or more was de ned as a ‘critical score’. 10,11