The impact of Early Warning Score and Rapid Response Systems on nurses’ competence: An integrative literature review and synthesis

Implementing Best Practices for Decreasing Nurse Hesitancy to Call the Rapid Response Team: An Evidence-Based Quality Improvement Initiative

BACKGROUND

Nurses, regardless of experience, sometimes wait for the Modified Early Warning Score to indicate physiological decline before initiating the hospital's Rapid Response Team (RRT). The goal of this quality improvement initiative was to reduce nurse hesitancy to call the RRT, as indicated by the monthly number of proactive calls before the Modified Early Warning Score increased and triggered an automated page.

METHOD

Education, planned handoff communication, debriefing, and good catch emails were the educational strategies used in the implementation of the quality improvement initiatives, encouraging RRT calls sooner. Increasing RRT knowledge and communication is an evidence-based practice strategy to reduce nurse reluctance to call the RRT.

RESULTS

After implementation, monthly proactive RRT calls increased (χ² [1, n = 1,964] = 14.6085, p = .000159). Bedside interventions, unscheduled transfers, and Acute Physiologic and Chronic Health Evaluation scores did not differ.

CONCLUSION

Education, structured handoff communication, and acknowledging good catches reduced nurses' reluctance to call the RRT proactively. [J Contin Educ Nurs. 2023;54(6):281-288.].

Is Modified Early Warning Score associated with clinical outcomes of patients admitted to a university internal medicine ward?

OBJECTIVE

To assess the MEWS association with the clinical outcomes (CO) of patients admitted to an internal medicine ward (IMW) at a Brazilian university hospital (UH).

INTRODUCTION

It is important to quickly identify patients with clinical deterioration, especially in wards. The health team must recognize and act before the situation becomes an adverse event. In Brazil, nurses' work to overcome performance myths and the application of standardized predictive scales for patients in wards is still limited.

DESIGN

An observational cohort study designed and developed by a registered nurse that followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

METHODS

Data were collected from the IMW of a UH located in the city of São Paulo, Brazil (2017). An ROC curve was calculated to strengthen the use of a MEWS of < or ≥ 4 as a cutoff. CO of the two subgroups were compared.

RESULTS

Three hundred patients completed the study; their vital signs were recorded consecutively throughout hospitalization in the IMW. The highest MEWS value each day was considered for analysis. Scores < 4 were significantly associated with a higher probability of hospital discharge, a lower chance of transfer to the ICU, a lower total number of days of hospitalization, and a lower risk of death. Score ≥ 4 had worse CO (orotracheal intubation and cardiac monitoring), transfer to the ICU, and increased risk of death.

CONCLUSION

Scores < 4 were associated with positive outcomes, while scores ≥ 4 were associated with negative outcomes. MEWS can help prioritize interventions, increase certainty in decision-making, and improve patient safety, especially in a teaching IMW with medical teams undergoing professional development, thereby ensuring the central role of the nursing team in Brazil.

RELEVANCE FOR CLINICAL PRACTICE

MEWS aid nurses in identifying and managing patients, prioritizing interventions through assertive decision-making.

Rapid Response Team Activation Triggers in Adults and Children: An Integrative Review

PURPOSE

This integrative review aims to identify the triggers for rapid response team (RRT) activation and their outcomes in pediatric patients and to compare them with those of adult patients. In addition, this integrative review synthesizes the outcomes of cardiopulmonary resuscitation (CPR), intensive care unit (ICU) admission, length of hospital stay, and mortality following RRT activation.

METHOD

An integrative review using the Whittemore and Knafl methodology was undertaken with a search of three large databases (PubMed, Ovid MEDLINE, and CINAHL) and found 25 relevant studies published in the years 2017 through 2022.

RESULTS

Tachypnea, decreased oxygen saturation, tachycardia, changes in blood pressure, and level of consciousness were the most common triggers in both populations. However, specific activation triggers differed between children and adults.

CONCLUSIONS

The most common triggers for RRT are detectable through vital signs monitoring; therefore, vigilant tracking of patients' vital signs is critical and can provide early clues to clinical deterioration.

Implementation of a digital early warning score (NEWS2) in a cardiac specialist and general hospital settings in the COVID-19 pandemic: a qualitative study

OBJECTIVES

To evaluate implementation of digital National Early Warning Score 2 (NEWS2) in a cardiac care setting and a general hospital setting in the COVID-19 pandemic.

DESIGN

Thematic analysis of qualitative semistructured interviews using the non-adoption, abandonment, scale-up, spread, sustainability framework with purposefully sampled nurses and managers, as well as online surveys from March to December 2021.

SETTINGS

Specialist cardiac hospital (St Bartholomew's Hospital) and general teaching hospital (University College London Hospital, UCLH).

PARTICIPANTS

Eleven nurses and managers from cardiology, cardiac surgery, oncology and intensive care wards (St Bartholomew's) and medical, haematology and intensive care wards (UCLH) were interviewed and 67 were surveyed online.

RESULTS

Three main themes emerged: (1) implementing NEWS2 challenges and supports; (2) value of NEWS2 to alarm, escalate and during the pandemic; and (3) digitalisation: electronic health record (EHR) integration and automation. The value of NEWS2 was partly positive in escalation, yet there were concerns by nurses who undervalued NEWS2 particularly in cardiac care. Challenges, like clinicians' behaviours, lack of resources and training and the perception of NEWS2 value, limit the success of this implementation. Changes in guidelines in the pandemic have led to overlooking NEWS2. EHR integration and automated monitoring are improvement solutions that are not fully employed yet.

CONCLUSION

Whether in specialist or general medical settings, the health professionals implementing early warning score in healthcare face cultural and system-related challenges to adopting NEWS2 and digital solutions. The validity of NEWS2 in specialised settings and complex conditions is not yet apparent and requires comprehensive validation. EHR integration and automation are powerful tools to facilitate NEWS2 if its principles are reviewed and rectified, and resources and training are accessible. Further examination of implementation from the cultural and automation domains is needed.

How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study

AIM

To explore and describe how the National Early Warning Score (NEWS) and Individual Early Warning Score (I-EWS) are used and how they support nurses' patient risk assessment practice.

DESIGN

A qualitative observational fieldwork study drawing on ethnographical principles was performed in six hospitals in two regions of Denmark in 2019.

METHODS

Data were generated from participant observations and informal interviews with 32 nurses across 15 different wards in the hospitals. A total of 180 h of participant observation was performed. The observations lasted between 1.5 and 8 h and were conducted during day or evening shifts.

RESULTS

NEWS and I-EWS supported nurses' observations of patients, providing useful knowledge for planning patient care, and prompting critical thinking. However, the risk assessment task was sometimes delegated to less experienced staff members, such as nursing students and healthcare assistants. The Early Warning Score (EWS) systems were often adapted by nurses according to contextual aspects, such as the culture of the speciality in which the nurses worked and their levels of competency. In some situations, I-EWS had the effect of enhancing nurse autonomy and responsibility for decision-making in relation to patient care.

CONCLUSIONS

EWS systems support nurses' patient risk assessment practice, providing useful information. I-EWS makes it easier to factor the heterogeneity of patients and the clinical situation into the risk assessments. The delegation of risk assessment to other, less experienced staff members pose a risk to patient safety, which needs to be addressed in the ongoing debate regarding the shortage of nurses.

IMPACT

The findings of this study can help ward nurses, hospital managers and policymakers to develop and improve strategies for improved person-centred nursing care.

Features of the triggering of the yellow code and factors associated with the occurrence of adverse events

Objective:

to analyze the characteristics of the activation of the yellow code in wards and identify the factors associated with adverse events after the Rapid Response Team.

Methods:

a cross-sectional study with retrospective analysis of medical records of adults admitted to medical or surgical clinic wards of the University Hospital of São Paulo.

Results:

among the 91 patients, the most frequent signs of triggers (n=107) were peripheral oxygen saturation of less than 90% (40.2%) and hypotension (30.8%). Regarding the associated factors the research identified each minute of attendance of the Rapid Response Team in the wards increased by 1.2% odds of adverse events (twenty-four unplanned admission in the ICU and one cardiac arrest) in the sample (p=0.014).

Conclusions:

decreased oxygen saturation and hypotension were the main reasons for the triggering, and the length of care was associated with the frequency of adverse events.

Características do acionamento do código amarelo e fatores associados à ocorrência de eventos adversos

RESUMO Objetivo: analisar as características do acionamento do código amarelo em unidades de internação e identificar os fatores associados à ocorrência de eventos adversos após o atendimento do Time de Resposta Rápida. Métodos: estudo transversal com análise retrospectiva de prontuários de adultos internados em enfermarias de Clínica Médica ou Cirúrgica de hospital universitário de São Paulo. Resultados: entre os 91 pacientes, os sinais mais frequentes dos acionamentos (n=107) foram saturação periférica de oxigênio inferior a 90% (40,2%) e hipotensão arterial (30,8%). Quanto aos fatores associados, identificou-se que cada minuto de atendimento do Time de Resposta Rápida nas enfermarias aumentou em 1,2% a chance de ocorrência de eventos adversos (24 internações não planejadas em Unidade de Terapia Intensiva e uma parada cardiorrespiratória) na amostra (p=0,014). Conclusões: queda da saturação de oxigênio e hipotensão arterial foram os principais motivos de acionamento, e o tempo de atendimento foi associado à ocorrência de eventos adversos.

Effect of the national early warning score on monitoring the vital signs of patients in the emergency room

OBJECTIVE

To verify the effect of using the National Early Warning Score (NEWS) system on the compliance of the vital signs monitoring interval with those recommended for patients in the emergency room.

METHODS

This is a quasi-experimental, before-and-after study, performed in an emergency room with 280 adult patients selected by convenience. The effect of NEWS on the compliance of the vital signs monitoring interval with those recommended by the system was analyzed by linear regression.

RESULTS

In the Pre-NEWS phase, 143 patients were analyzed (mean age ± standard deviation: 54.4 ± 20.5; male: 56.6%) and, in the Post-NEWS phase, 137 patients (mean age ± standard deviation: 55.5 ± 20.8; male: 50.4%). There was compliance of the vital signs monitoring interval with what is recommended by NEWS in 92.6% of vital signs records after adopting this instrument. This compliance was 9% (p < 0.001) higher in the Post-NEWS phase.

CONCLUSION

The use of the NEWS system increased the compliance of the vital signs monitoring intervals with the ones recommended, but this compliance decreased when the NEWS score pointed to a shorter interval in the monitoring of vital signs.

Efeito do national early warning score no monitoramento dos sinais vitais de pacientes no pronto-socorro

RESUMO Objetivo: Verificar o efeito do uso do sistema National Early Warning Score (NEWS) na conformidade do intervalo de monitoramento dos sinais vitais com o recomendado em pacientes no pronto-socorro. Método: Estudo quasi-experimental, do tipo antes e depois, realizado em um pronto-socorro com 280 pacientes adultos selecionados por conveniência. O efeito do NEWS na conformidade do intervalo de monitoramento dos sinais vitais com o recomendado pelo sistema foi analisado por regressão linear. Resultados: Na fase Pré-NEWS, foram analisados 143 pacientes (idade média ± desvio-padrão: 54,4 ± 20,5; sexo masculino: 56,6%) e, na fase Pós-NEWS, 137 pacientes (idade média ± desvio-padrão: 55,5 ± 20,8; sexo masculino: 50,4%). Houve conformidade do intervalo de monitoramento dos sinais vitais com o recomendo pelo NEWS em 92,6% dos registros de sinais vitais após adoção desse instrumento. Essa conformidade foi maior na fase Pós-NEWS em 9% (p < 0,001). Conclusão: O uso do sistema NEWS aumentou a conformidade dos intervalos de monitorização dos sinais vitais com o recomendado, porém essa conformidade diminuiu quando o escore NEWS apontou para intervalo menor no monitoramento dos sinais vitais.

Using an early warning score for nurse shift patient handover: Before-and-after study

PURPOSE

This study aimed to examine the impact of using an early warning score for shift patient handover on nurse and patient outcomes.

METHODS

A before-and-after study was conducted with nurses and patients in three general wards in a tertiary teaching hospital. A short-time nurse education on the National Early Warning Score 2 and the use of a checklist for score calculation were performed from June 4, 2019 to June 30, 2019. Outcomes of nurse response (safety competency, handover quality, teamwork, safety climate, and documentation of vital signs and clinical concerns), patient response (deterioration occurrence post-admission, hospitalization length, and discharge status), and adverse events (mortality, cardiopulmonary arrest, and unplanned intensive care unit admission) were measured using questionnaires and medical record reviews. Data from 89 nurses and 388 patients were analyzed.

RESULTS

Regarding nurse outcomes, handover quality (p <.001), teamwork (p = .004), safety climate (p = .018), and recordings of vital signs (p = .047) and clinical concerns (p = .008) increased after early warning score use. However, no significant change in the safety competency scores was observed. Regarding patient outcomes, there were no significant changes in the occurrence of deterioration, hospitalization length, discharge status, and occurrence of adverse events between pre-and-post intervention.

CONCLUSION

Despite no significant changes in patient outcomes, using a simple, evidence-based early warning score for patient handover enhanced socio-cultural factors for patient safety, with improved patient monitoring. The findings provide evidence that supports the active implementation of an early warning score to improve patient safety.

Development of a comprehensive model for the role of the rapid response team nurse

OBJECTIVE

To develop a comprehensive model of the role of the rapid response team nurse.

DESIGN

Using an experience-based co-design approach, qualitative data concerning the categories and components of the role of the rapid response team nurse were generated via workshops and one-on-one interviews with service users and providers. The appropriateness of the comprehensive model was evaluated through an online survey.

SETTING

Forty-six tertiary hospitals across South Korea. A total of 114 rapid response team service providers and users were recruited using convenience sampling.

FINDINGS

The comprehensive model included the requirements, facilitating factors, barriers, and outcomes as well as the roles and tasks of rapid response team nurses. The key roles in the final model were found to be: 1) Screening of patients with acute exacerbation, 2) Professional support for emergencies, 3) Education for service users, 4) Consultation for high-risk patient care, 5) Support for patient and family decision-making, 6) Coordination between departments, and 7) Management of the rapid response team. These roles contain 57 specific tasks. Rapid response team professionals finalised the model by evaluating the appropriateness of its components.

CONCLUSION

An experience-based co-design approach was used to develop a comprehensive model that reflects the insights and needs of rapid response team service users and providers. We recommend that the model be validated and supplemented by data from different institutions and countries.

Implementing technology to support the deteriorating patient in acute care: evaluating staff views

BACKGROUND

Early warning scores (EWS) have been widely used to aid in the detection of deterioration. The use of technology, alongside EWS, may improve patient safety and lead to improvements in the accuracy of documentation.

AIM

The aim of this service evaluation was to understand nurses' and healthcare support worker views around the implementation of handheld electronic devices for documenting care related to the deteriorating patient.

METHODS

Before the implementation of an electronic handheld device, in-depth semi-structured interviews with nursing staff and healthcare support workers were undertaken to explore the context for improvement. The Consolidated Framework for Implementation Research was used to analyse, organise and present data, to ensure systematic inquiry across the range of potential facilitators and challenges perceived by staff. In all, 11 interviews were undertaken across three speciality areas (four wards).

FINDINGS

Challenges to the use of new technology included staff apprehension around training and education needs and the uncertainty of technological reliability in the clinical setting. Potential facilitators to support the implementation of this technology were: the potential for improved communication across the individual ward and hospital setting and the potential for more streamlined processes for escalation of concerns.

CONCLUSION

Three main recommendations for practice emerged. First, nurses should be involved in the development of the systems. Appropriate time is required to embed the technology in practice. Finally, thought must be given not just to the absolute number of devices required and their reliability, but also how new technology interacts in each individual context.

Interviews with Community Healthcare Registered Nurses in Norway: Examination Practices and Clinical Evaluation Processes

Aim

This study describes the examination practices and clinical evaluation processes that Registered Nurses in Norway perform in the community healthcare sector.

Design

A qualitative exploratory design.

Methods

Twenty interviews were conducted with Registered Nurses employed in the community healthcare sector in Norway. The data were analysed using a thematic analysis.

Results

We found four major themes: (1) evaluations are embedded in nurses’ daily work, (2) significance of a Registered Nurse's clinical competency, (3) different tasks require various roles and (4) access to resources and equipment. Registered Nurses possess several skills in a range of different examination techniques and clinical evaluation processes in the community healthcare sector. They perform complex assessments in their daily work and must rely on other healthcare professionals, facilities and equipment to provide high‐quality care. Ongoing education and training will enable Registered Nurses to complete accurate assessments in their community healthcare practice.

Survey of Nursing Staff's Training on Early Warning Ability for Inpatients with "Three Infarcts and One Hemorrhage"

Methods

A total of 787 nursing staff in a tertiary referral center in Changsha City, Hunan Province, were selected using a convenient sampling method. We used an online questionnaire designed by ourselves to survey them. The content of the questionnaire primary included basic information, related knowledge of the nursing staff on the potential risk prediction and precontrol of inpatients with "three infarcts and one hemorrhage," relevant information on improving early warning scores, management of clinical early warning, training needs, and training methods.

Results

Over 50% of the nursing staff had little understanding about the risk warning knowledge of inpatients with "three infracts and one hemorrhage," and the degree of understanding was related to education, job title, and working years. The nursing staff with higher education level or professional title or longer working experience have a better understanding of the risk warning knowledge of inpatients with "three infracts and one hemorrhage."

Conclusion

The cognitive competence of nursing staff in a tertiary referral center in Changsha City, Hunan Province, on the early warning ability of inpatients with "three infarcts and one hemorrhage" needs to be improved. Medical institutions should actively train nursing staff on early warning ability for inpatients with "three infarcts and one hemorrhage" to improve the nursing staff's awareness and patients' safety and efficiency.

Assessing acute functional decline in older patients in home nursing care settings using the Modified Early Warning Score: A qualitative study of nurses' and general practitioners' experiences

AIMS AND OBJECTIVES

The study describes experiences of registered nurses and general practitioners when using the Modified Early Warning Score (MEWS) to assess acute functional decline in older home nursing care patients.

BACKGROUND

Acute functional decline is common among older home nursing care patients; typically characterised by nonspecific symptoms and a mix of manifestations. Early warning score systems for detecting clinical deterioration have been thoroughly evaluated in hospital settings, but few studies have evaluated these systems used with older people in a community care setting.

METHODS

A descriptive exploratory research design and a qualitative approach. 36 nurses and eight general practitioners were purposively sampled. Data were collected in seven mixed focus groups and analysed using an inductive thematic content analysis in an iterative process that moved between text, codes, categories and themes. The COREQ checklist was used.

RESULTS

Two main themes were developed in the analysis. The first theme derived, was that the MEWS along with medical-technical equipment and clinical judgement, was used to support nurses' and general practitioners' clinical decisions in assessing older deteriorating patients. The second theme referred to nurses' and general practitioners' experiences with several adjustments when using the MEWS with the older patient group and in complying with its trigger recommendations.

CONCLUSION

The use of the MEWS when assessing older patients in home nursing care is potentially useful in supporting clinical reasoning. However, the tool's usefulness is limited because it is not experienced as sufficiently adapted to neither the home nursing care services nor to older patients.

IMPLICATIONS FOR PRACTICE

This study increases our knowledge of how the MEWS tool is used in a community care setting and highlights the importance of adjustment of assessment procedures for older persons with acute functional decline.

A systematic review of rapid response applications based on early warning score for early detection of inpatient deterioration

AIM

The aim of this study was to investigate the effectiveness of current rapid response applications available in acute care settings for escalation of patient deterioration. Current challenges and barriers, as well as key recommendations, were also discussed.

METHODS

We adopted PRISMA review methodology and screened a total of 559 articles. After considering the eligibility and selection criteria, we selected 13 articles published between 2015 and 2019. The selection criteria were based on the inclusion of studies that report on the advancement made to the current practice for providing rapid response to the patient deterioration in acute care settings.

RESULTS

We found that current rapid response applications are complicated and time-consuming for detecting inpatient deterioration. Existing applications are either siloed or challenging to use, where clinicians are required to move between two or three different applications to complete an end-to-end patient escalation workflow - from vital signs collection to escalation of deteriorating patients. We found significant differences in escalation and responses when using an electronic tool compared to the manual approach. Moreover, encouraging results were reported in extensive documentation of vital signs and timely alerts for patient deterioration.

CONCLUSION

The electronic vital signs monitoring applications are proved to be efficient and clinically suitable if they are user-friendly and interoperable. As an outcome, several key recommendations and features were identified that would be crucial to the successful implementation of any rapid response system in all clinical settings.

A clinical competence approach to examine British and Finnish nurses' attitudes towards the rapid response system model: A study in two acute hospitals

BACKGROUND

Nurses' clinical competence involves an integration of knowledge, skills, attitudes, thinking ability, and values, which strongly affects how deteriorating patients are managed.

OBJECTIVES

The aim of the study was to examine nurses' attitudes as part of clinical competence towards the rapid response system in two acute hospitals with different rapid response system models.

METHODS

This is a comparative cross-sectional correlational study. A modified "Nurses' Attitudes Towards the Medical Emergency Team" tool was distributed among 388 medical and surgical registered nurses in one acute hospital in the UK and one in Finland. A total of 179 nurses responded. Statistical analyses, including exploratory factor analysis, Mann-Whitney U tests, Kruskal-Wallis tests, chi-square tests, and univariate and multivariate regression analyses, were used.

FINDINGS

Generally, nurses had positive attitudes towards rapid response systems. British and Finnish nurses' attitudes towards rapid response system activation were divided when asked about facing a stable (normal vital signs) but worrisome patient. Finnish nurses relied more on intuition and were more likely to activate the rapid response system. Approximately half of the nurses perceived the physician's influence as a barrier to rapid response system activation. The only sociodemographic factor that was associated with nurses activating the rapid response system more freely was work experience ≥10 years.

CONCLUSIONS

The findings are beneficial in raising awareness of nurses' attitudes and identifying attitudes that could act as facilitators or barriers in rapid response system activation. The study suggests that nurses' attitudes towards physician influence and intuition need to be improved through continuing development of clinical competence. When the system model included "worrisome" as one of the defined parameters for activation, nurses were more likely to activate the rapid response system. Future rapid response system models may need to have clear evidence-based instructions for nurses when they manage stable (normal vital signs) but worrisome patients and should acknowledge nurses' intuition and clinical judgement.

Update on early warning scores

Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.

Hospital nurses' professional accountability while using the National Early Warning Score: A qualitative study with a hermeneutic design

AIM

To explore general hospital ward nurses' experiences with the National Early Warning Score and to determine its impacts on their professionalism.

BACKGROUND

The National Early Warning Score has broad appeal; it is a patient safety initiative designed to ensure early identification of and response to deteriorating patients in hospitals. However, it is still unclear how the tool impacts nurses' professionalism.

METHODS

A qualitative study with a hermeneutic design was conducted in autumn 2017; the study consisted of semi-structured, in-depth interviews with 14 hospital nurses. The data were analysed thematically to understand and interpret the nurses' experiences. Methods are reported using COREQ guidelines (see Appendix S1).

RESULTS

The study examined nurses' experience with the National Early Warning Score and its perceived impact on their professionalism. Four themes were identified: (a) the National Early Warning Score and clinical judgement in patient assessment, (b) responding to the National Early Warning Score standard, (c) involving the professional community and (d) adjusting the tool.

CONCLUSION

The National Early Warning Score may impact nurses' professionalism in diverse ways. Nurses are aware of the importance of incorporating all of their professional competence, comprising clinical judgement, discretion and accountability, with the National Early Warning Score to accurately assess patients' conditions. Findings indicated that the National Early Warning Score was beneficial to nurses' professional practice; however, accountability to this standard alone does not ensure quality care and patient safety.

RELEVANCE TO CLINICAL PRACTICE

A greater understanding of the role of nurses' professional accountability when using the National Early Warning Score is needed to improve practice and ensure patient safety.

Introducing the National Early Warning Score - A qualitative study of hospital nurses' perceptions and reactions

AIM

The aim of this study was to explore hospital nurses' perceptions and reactions to the National Early Warning Score during an introduction programme.

DESIGN

A qualitative case study approach with participatory observations was used for this study.

METHODS

In total, nine seminars and 23 simulation sessions attended by nurses were observed. An activity theory system analysis was applied to interpret the material.

RESULTS

The findings revealed four tensions related to the working context: (a) tension between using a standardized tool and relying on clinical judgement (the tool could be either an aid or a barrier to patient assessment); (b) tension in the community of practice (the tool could be beneficial or increase stress and anxiety); (c) tension related to rules and compliance (the tool could be perceived as optional or compulsory); and (d) tension related to the division of labour (nurses feared more work).

The National Early Warning Score predicts mortality in hospital ward patients with deviating vital signs: A retrospective medical record review study

AIMS AND OBJECTIVES

To evaluate whether the scale used for assessment of hospital ward patients could predict in-hospital and 30-day mortality amongst those with deviating vital signs; that is, that patients classified as medium or high risk would have increased risk of in-hospital and 30-day mortality compared to patients with low risk.

BACKGROUND

The National Early Warning Score (NEWS) is a widely adopted scale for assessing deviating vital signs. A clinical risk scale that comes with the NEWS divides the risk for critical illness into three risk categories, low, medium and high.

DESIGN

Retrospective analysis of vital sign data.

METHODS

Logistic regression models for age-adjusted in-hospital and 30-day mortality were used for analyses of 1,107 patients with deviating vital signs.

RESULTS

Patients classified as medium or high risk by NEWS experienced a 2.11 or 3.40 increase, respectively, in odds of in-hospital death (95% CI: 1.27-3.51, p = 0.004% and 95% CI: 1.90-6.01, p < 0.001) compared to low-risk patients. Moreover, those with NEWS medium or high risk were associated with a 1.98 or 3.19 increase, respectively, in odds of 30-day mortality (95% CI: 1.32-2.97, p = 0.001% and 95% CI: 1.97-5.18, p < 0.001).

CONCLUSION

The NEWS risk classification seems to be a reliable predictor of mortality on patients in hospital wards.

RELEVANCE TO CLINICAL PRACTICE

The NEWS risk classification offers a simple way to identify deteriorating patients and can aid the healthcare staff to prioritise amongst patients.