THE MARSI MEWS Dr Sara McCluskey and Dr Paul Robinson

• Evolution of the MARSI MEWS

• Results of audit

• Validation

Meet the MARSI MEWS team

Kat Damazer –

Assistant Psychologist

Karishma Talwar-

EDU Healthcare Assistant

Dr Sara McCluskey–

Consultant Psychiatrist

With Special thanks to :

• Dr Paul Robinson – project design

• Jacob Hollis – data analysis

• Dr Francis Connan – data collection

• Dr Sonu Sharma – data collection

• Steven Stokes – Initial audit

• The staff of the EDUs at the Priory Hospital Southampton, Roehampton, Bristol, Cheadle and Hayes Grove

• The staff of the EDU Vincent Square Central and Northwest London NHS Trust

Current Risk Assessment Tools for Community Patients with Anorexia Nervosa

• Mausdley “Rough Guide” – Professor Janet Treasure

• PREDIX John Morgan

SYSTEM TEST* OR INVESTIGATION CONCERN ALERT

Nutrition BMI <14 <12

Weight Loss/Week >0.5 kg >1.0 kg

Skin Breakdown <0.1cm >0.2 cm

Purpuric Rash +

Circulation Systolic BP <90 <80

Diastolic BP <70 <60

Postural Drop (Sit - Stand) >10 >20

Pulse Rate <50 <40

Musculo-skeletal (Squat Test)

Unable to get up without using arms for balance yellow

+

Unable to get up without using arms as leverage (red)

+

Temperature <35 98.0 F

<34.5C <97.0 F

Bone Marrow WCC <4.0 <2.0

Neutrophil Council <1.5 <1.0

Hb <11 <9.0

Acute Hb Drop (MCV and MCH raised - no acute risk)

+

Platelets <130 <110

Salt/Water Balance

K+ <3.5 <3.0

2. Na+ <135 <130

3. Mg++ 0.5-0.7 <0.5

4. PO4-- 0.5-0.8 <0.5

5. Urea >7 >10

Liver Bilirubin >20 >40

Alkpase >110 >200

AsT >40 >80

ALT >45 >90

GGT >45 >90

Nutrition Albumin <35 <32

Creatinine Kinase >170 >250

Glucose <3.5 <2.5

Differential Diagnosis

TFT, ESR

ECG Pulse Rate <50 <40

QTc Interval >500ms

Arrythmias +

* The baselines of these tests vary between labs. Any abnormal result is an indication for

concern and monitoring.

Rough Guide :Janet Treasure

ROUGH GUIDE TO A SUMMARY MEASURE OF RISK

Analogue of Risk Management:

1. No Coloured Scores

Regular review and monitoring of above parameters with routine referral to eating disorders

unit/ secondary services depending on local resources.

2. Score(s) in the Yellow/Concern Area

Regular review of parameters (c. weekly) and assessment of capacity with urgent referral to

eating disorders and appropriate medical intervention if needed.

3. Score(s) in the Red/Alert Area

Immediate contact and referral to eating disorders unit and physicians if outpatient with

assessment of capacity. The patient will need urgent specialist and medical assessment. If

inpatient - immediate contact with on-call physicians.

This table gives values of concern for each part of the assessment and is followed by a

management protocol based on risk.

Please turn over.

John Morgan et al 2013

Why a Modified Early Warning System for EDU’s

• Trusts’ expectation for use of NEWS

• Concerns that this not “fit for purpose” for ED patients

– False positives and false negatives

• Development of adaptations of NEWS for specific clinical groups e.g. PEWS

NEWSRoyal College of Physicians 2013

“MARSI” MEWS using information from physical observations effectively on inpatient EDUs

• MEWS - Modified Early Warning Score

• NEWS - National Early Warning Score

• “MARSI” MEWS – Development of a Meaningful Early Warning Score for Inpatient Eating Disorder Units

MARSI MEWS

Development

• Setting of MARSI MEWS parameters informed by

– Reference to existing community physical risk assessment tools

– Review of patients observation charts at Hayes

– Consultation with MARSIPAN physician

– Consultation via EDSIG list serve

Observation NEWS MARSI MEWS

Systolic BP (mm Hg) 111-219 90-140

Respiratory rate (breaths / min) 12-20 10-20

Postural drop (mm Hg) Not included <10

Pulse rate (BPM) 51-90 51-90

Temperature (°C) 36-38 36-37

O2 saturation >96 No score. < 95% contact RMO

AVPUA

(V P U score 3)

No score.

Other than Alert contact RMO

NEWS and MARSI MEWS parameters

Observation

MARSI MEWS SCORE

1 2 3

Systolic BP (mm Hg) >140 <90, >150 <80, >160

Respiratory rate (breaths / min) >20 <10, >25

Postural drop (mm Hg) >10 >20 >30

Pulse rate (BPM) <50, >90 >100 <40, >110

Temperature (°C) >37 <36, >38 <35, >39

Parameters

Development

• Design of MARSI MEWS Chart

– Piloted at Hayes Grove

• Exclusion of blood sugar from MARSI MEWS score calculation

• BM measurement of less than 5 triggers instructions on reverse of chart

Modification of MARSI MEWS following pilot at Hayes

Development

• Design of MARSI MEWS Chart

– Trialled on 6 Priory and one NHS sight following structured teaching

Development and training issues

• Importance of respiratory rate assessment, recording and scoring to be highlighted to staff

– Respiratory rate is an vital indicator of many bodily functions i.e. respiratory problems, cardiovascular problems, metabolic problems, neurological problems

• Clarification of recording and scoring of BP measurements

– one score for sitting systolic BP

– Second score for difference between sitting and standing BP

Development

– Audit of

• Usability of Chart

• NEWS versus MARSI MEWS scores

Usability of Chart

47%

7%

2%1%

38%

5%

Percentage of Missing Observations from MARSI MEWS chart entries n= 3585

respiratory rate

temperature

pulse

systolic sitting BP

systolic standing BP

O2 sat

Usability – not all observations taken

50%50%

Complete observation sets

Incomplete observation sets

MARSI MEWS scores

60%

40%Unrecorded total MEWS score

Recorded total MEWS score

Recorded MARSI MEWS scores

89%

11%

Correctly recorded total MEWS scores

Incorrectly reported total MEWS scores

MARSI MEWS and NEWS compared

MEWS and NEWS sameMEWS scores higher than

NEWSMEWS scores lower than

NEWS

Series1 458 369 975

0

200

400

600

800

1000

1200

Nu

mb

er

of

MA

RSI

MEW

S ch

arts

Figure 4: A chart to illustrate the difference between NEWS and MARSI MEWS scores obtained from the valid MARSI MEWS CHARTS (n=1802)

MARSI MEWS GROWS UP –do we eat it or play with it ?

The MARSI MEWS Study Phase 2

• Phase 1 has resulted in a large database of physical observations and corresponding MARSI MEWS and NEWS scores.

• The NEWS and the MARSI MEWS are different: NEWS scores tended to be higher than the corresponding MARSI MEWS score- is the NEWS too sensitive?

• Phase 2: To determine if the MARSI MEWS (an adapted version of the NEWS) is a better predictor of physical deterioration in inpatients with anorexia nervosa than the NEWS.

Patient Profiles

• We have compiled information on 60 patients from 2 units to create Patient Profiles.

• Profiles include STATE variables, showing the physical health of a patient on a given day (including the observations on the MARSI MEWS chart)

• And TRAIT variables with information regarding physical and psychiatric medical history.

Patient Profiles State Variables

Patient ID: Date of MARSI MEWS observation:

Respiratory Rate

Temperature

Pulse

Systolic BP Sitting

Postural Drop

O2 Saturation

State of Consciousness (AVPU)

BMI

Most Recent ECG (please include date and

any abnormal findings)

Current Physical Co-Morbidities

Current Psychiatric Co-Morbidities

Days Since Admission

Most Recent Blood Profile (only include

abnormal results. Look just at the following:

Neutrophil, Phosphate, Urea, Creatinine,

Haemoglobin and Potassium)

Current Medications (including dose)

Patient Profiles Trait Variables

Diagnosis (Anorexia Nervosa restrict or

binge/purge)

Years since onset of Anorexia

Current Age

Longstanding Physical Co-Morbidities

Longstanding Psychiatric Co-Morbidities

Diagnosis of Personality Disorder

YOUR MISSION (should you choose to accept it)!

• We would like you to examine the Patient Profiles handed out to you and indicate on the scoring sheet which clinical action you feel is most appropriate if you were confronted with this patient in an inpatient setting.

• There is also a space for any comments at the bottom of each scoring sheet.

• We will then compare this to the MARSI MEWS and NEWS scores that each profile would have scored.

• We will assess which tool (MARSI MEWS or NEWS) produces scores that best match the opinions of the clinicians (you!) as to which of the Patient Profiles are considered to be at risk of physical deterioration.

About You

Workshop 3: Early Intervention for physical decompensation. Questionnaire

ID: Please make up an ID (eg a relative’s first name and birth year) and copy it onto your Response sheet [………………….] Profession (tick): Psychiatry [ ] Other (specify) [ ] Specialty: (tick): General adult [ ] Eating Disorders [ ] Child and Adolescent [ ] Other (specify) ………………………………………. Role: (tick): Consultant [ ] Senior trainee [ ] Junior trainee [ ] Associate specialist [ ] Trust doctor [ ] Other (specify) ………………………………………. Clinical Practice (tick all that apply) NHS [ ] Private [ ] Outpatients [ ] Inpatients [ ] Day-patients [ ] General medical or paediatric ward [ ] Full time [ ] Part time [ ] Number of sessions [ ] Years in Eating Disorders 0-5 [ ] 5-10 [ ] >10 [ ] Do you give us permission to use the data collected anonymously to develop the MARSIMEWS assessment? Yes No (please circle) Thank you Sara McCluskey and Paul Robinson

Your Assessment

Workshop 3: Early Intervention for physical decompensation. Questionnaire

ID: (from questionnaire) […………………………….] Case number (from Patient Profile) Assessment of risk (please tick most appropriate)

Your comments about the most appropriate management of this case ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Additional comments following discussion with your neighbour ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Thank you Sara McCluskey and Paul Robinson

High Consult RMO and Consultant immediately

Medium-High Observations every 30 minutes and RMO to attend immediately

Medium Hourly observations, call RMO to attend within 30 minutes

Low Complete observations every 4 hours

Minimal Continue with Routine monitoring