When Norma Noesgaard started working on Surgery 5000 at Royal University Hospital (RUH) in January 2012, she was amazed at the number of patients who were being transferred to the intensive care unit (ICU). At the time, they were seeing four to 10 transfers per month, for an annual total of 76.

“We knew we had to provide safer care for our patients,” says Noesgaard, Manager of Surgery 5000. “So, I asked our Clinical Nurse Educator, Marla Regier, to do some research to find out if there was such a thing as an adult early warning scoring system.”

Based on the information that Regier found, a Patient Assessment Scoring System (PASS) was created, and on October 1, 2014, the unit began trialing it. To date, they have seen a more than 50 per cent decrease in patient transfers to the ICU, from 33 per year in 2014 to 15 in 2015. The system has also allowed the unit to decrease code blues or cardiac arrests by nearly 70 per cent, from seven in 2014 to two in 2015.

PASS is an early warning scoring system that detects and identifies patients who have signs of deterioration and ensures that appropriate nursing and medical interventions are acted upon.

“PASS is allowing us to initiate proactive treatment before patients get worse and go into cardiac arrest or require an ICU transfer, as opposed to having to react after they get too sick,” says Regier.

“It’s creating a safety net for patients who are deteriorating or who have the potential to deteriorate and is prompting us to activate the proper supports for these patients early in their treatment,” Noesgaard adds, explaining that when patients get to the point where they need to be moved to the ICU, they have often succumbed to sepsis (an infection in the bloodstream) and have suffered significant organ damage as a result; many patients never fully recover.

“That was not how we wanted patients to be leaving 5000,” says Noesgaard. “It was not acceptable.”

How PASS works

RUH Surgery 5000’s PSAG board.

RUH Surgery 5000’s PSAG board.

Upon arrival to Surgery 5000, all patients have their vital signs and level of consciousness assessed. The assessment is done every four hours for the first 24 hours, unless required or ordered more frequently. After the first 24 hours, the PASS assessment is complete and the patient is assigned a score (colour magnet) that is placed beside their room number on the unit’s patient-status-at-a-glance (PSAG) board.

“The PSAG boards allow the staff on our unit to know how a patient is doing at a glance,” says Regier. “We also have a physician board that has all 34 patient room numbers and a colour-coordinated magnet, so when physicians come on the unit, they can look at the board and know their patients’ conditions. We encourage them to go to any yellows or reds first when they come on their shift, so they see the sickest patients first.”

The patient’s PASS score determines when the next PASS assessment is completed. For example:

  • If the PASS score is 0 or Green, the patient is re-assessed and re-scored two times every 24 hours.
  • If the PASS score is 1-2 or Green, the patient is re-assessed and re-scored four times every 24 hours.
  • If the PASS score is 3-5 or Yellow, the patient is re-assessed and re-scored every four hours and as needed. The most responsible physician or resident is notified and comes to the unit within 60 minutes to assess the patient. The charge nurse is notified and evaluates who is or should be caring for the patient and re-assigns care as needed.
  • If the PASS score is 6 or more or Red, the patient is re-assessed and re-scored every two hours and as needed. The most responsible physician or resident is notified immediately and comes to the unit within 15 minutes. The charge nurse is also notified. A senior registered nurse takes over the care of the patient, who is placed in an observation unit. An ICU consult may also occur.

“A goal we have set for our unit is for nobody to get a red score,” says Noesgaard, adding that Surgery 5000 hasn’t seen a red score in a long time.

Staff response to PASS

PASS is having a positive impact on staff morale.

“Our patients are safer, and our staff is proud as a result,” says Noesgaard. “It’s becoming the language that staff and physicians use.”

“When we meet in the morning, we talk about the colours we have that day,” explains Regier.
“What we’ve found is that talking the language brings the anxiety level down in the morning. Staff used to come in and say, ‘It’s going to be a crazy day.’ But when they know at the outset that all our patients are green or we have only one or two yellows, it’s going to be a good day.”

Regier says the system is also helping new staff, especially recent grads.

“They feel validated when the system confirms that their nursing instincts are correct. It gives them the okay to do what they think they should do,” says Regier. “They’ve told us that it helps them feel stronger in their nursing skills, so in that way, PASS has strengthened our team.”

RUH Surgery 5000 is currently the only unit in the Region using PASS, but it is available to all units.

“We’d love to help another unit get up and running with it,” says Regier. “But from our experience, it has to be the right unit at the right time: a unit with a strong leadership team that wants to make improvements, a unit that’s fully staffed and a unit with staff who are committed to change.”

Interested in learning more about PASS? Contact Norma Noesgaard  or Marla Regier.