either scoring too high or too low (Figure 2). Analysis
revealed that the presence of patients' baseline abnormalities
accounted for these discrepancies:
• Behavior: baseline seizures
• Cardiovascular: baseline arrhythmias
• Respiratory: baseline use of supplemental oxygen flow
rate, baseline cyanosis.
The tool was modified such that should a patient have any
of these pre-existing abnormalities at baseline they would not
score high, whereas if a patient had a new onset of any of
those clinical findings, or it was unknown whether this was
normal for the patient (i.e. new admission), the findings
would still generate a higher C-CHEWS score.
The third and last pilot event (n=20; observations=119)
with the updated C-CHEWS tool demonstrated 100% of the
C-CHEWS scores matched the acuity of patients' clinical
presentations (Figure 2). The final version of the C-CHEWS
tool was approved for use on the cardiac unit (Figure 3) and
the Escalation of Care Algorithm (Figure 4) conformed with
existing critical response structures within the Cardiovascular
Program.
The Escalation of Care Algorithm is an escalation of
resources to a patient's bedside to assess and treat
deterioration based upon the C-CHEWS score. A CCHEWS
score of 0–2 (color code: green) recommends for
clinicians to continue routine care, monitoring and assessments.
A C-CHEWS score of 3–4 (color code: yellow)
instructs the patient's nurse to notify the charge nurse and
patient's resident or nurse practitioner of the elevated score.
These clinicians discuss as a team a treatment plan for the
patient, initiate the plan and increase the frequency of patient