Attitudes of nursing staff towards a Modified Early Warning System

The Effect of Modified Early Warning Score (MEWS) and Nursing Guide Application on Postoperative Patient Outcomes: A Randomized Controlled Study

PURPOSE

The aim of this study is to determine the effect of nursing guide application (NGA) on patient outcomes in patients followed up according to the modified early warning score (MEWS) in the postoperative period.

DESIGN

A randomized controlled clinical trial.

METHODS

The sample of the study consisted of 252 patients who underwent surgical intervention under general anesthesia in a university hospital between July 29, 2022, and October 31, 2022.

FINDINGS

Results showed that the development of complications was less in the study group (SG) compared to the control group (CG) during anesthesia (P = .027), in the postanesthesia care unit (PACU) (P = .017), and in the clinic (P = .001). It was found that the duration of stay in PACU in the CG was significantly shorter than in the study group (P < .001), and as the duration of stay in PACU in CG decreased, the MEWS increased (r = -0.201, P = .024). We found that there were fewer patients transferred to the intensive care unit (ICU) after PACU (P = .007), the MEWS was lower, and the number of nursing interventions applied to patients was higher (P < .05).

CONCLUSIONS

In patients followed up according to MEWS, NGA had a positive effect on preventing the development of complications and shortening the intervention time for complications, decreasing ICU admission, decreasing MEWS and increasing the number of nursing interventions. Based on the results, it may be recommended to use MEWS+NGA in the early postoperative period as it positively affects patient outcomes.

Early warning tools and clinician 'agency' for strengthening safety culture: An integrative review

AIM

Identify and analyse literature investigating nurses' and midwives' use of early warning tools during the care of adult inpatients.

DESIGN

An integrative literature review.

METHODS

Whittemore and Knafl's (2005) framework guided this integrative review. PubMed, CINAHL, EMCARE and Google Scholar were systematically searched. The authors assessed the methodological quality of 21 papers meeting inclusion criteria and thematically analysed key data.

RESULTS

Three main themes were identified, each with further sub-themes.

CONCLUSION

Early warning tools operate within various systems and cultural contexts. However, their potential for improved patient safety may be hindered. Protocols influencing tool usage may make nurses and midwives distanced from patients and their expertise. For early warning tools to enhance patient safety, assessing their integration into practice is crucial to maximizing effectiveness.

IMPACT

This review emphasizes the importance of integrating human relationships with early warning tools for patient safety.

PATIENT OR PUBLIC CONTRIBUTION

This integrative literature review does not include patient or public input.

IMPLICATIONS FOR PRACTICE/POLICY

Adapting early warning tools to balance standardization for safety and efficiency and promoting nurses' and midwives' expertise and autonomy is required to optimize delivery of quality care and uphold patient safety.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used.

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.

Factors that influence hospital nurses' escalation of patient care in response to their early warning score: A qualitative evidence synthesis

BACKGROUND

The Early Warning Score (EWS) is a validated tool that has improved patient outcomes internationally. This scoring system is used within the hospital setting to identify potentially deteriorating patients, thus expediting referral to appropriate medical personnel. It is increasingly recognised that there are other influencing factors along with EWS, which impact on nurses' decisions to escalate care.

AIM

The aim of this review was to identify and synthesise data from qualitative studies, which examined factors influencing nurses' escalation of care in response to patients' EWS.

METHODS

The systematic search strategy and eligibility criteria were guided by the SPIDER (Sample Phenomenon of Interest Design Evaluation Type of Research) framework. Eleven databases and five grey literature databases were searched. Titles and abstracts were independently screened in line with pre-established inclusion and exclusion criteria using the cloud-based platform, Rayyan. The selected studies underwent quality appraisal using CASP (Critical Appraisal Skills Programme, 2017, https://www.casp-uk.net/casp-toolschecklists) and subsequently synthesised using Thomas and Harden's thematic analysis approach. GRADE-CERQual (Grading of Recommendations Assessment Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in results. The EQUATOR listed guideline ENTREQ (Tong et al., 2012, BMC Medical Research Methodology, 12) was used to synthesise and report findings.

RESULTS

Eighteen studies from seven countries including 235 nurses were identified. Following synthesis, four analytical themes were generated with eighteen derived consequent findings. The four themes identified were as follows: 1) Marrying nurses' clinical judgement with EWS 2) SMART communication 3) EWS Protocol: Blessing and a Curse 5) Hospital Domain.

CONCLUSION

Nurses strive to find balance by simultaneously navigating within the boundaries of both the EWS protocol and the hospital domain. They view the EWS as a valid essential component in the system but one that does not give a definitive answer and absolute direction. They value the protocols' ability to identify deteriorating patients and convey the seriousness of a situation to their multidisciplinary colleagues but also find it somewhat restrictive and frustrating and wish to have credence given to their own intuition and clinical judgement.

Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Background

Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS).

Methods

A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorised into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.

Results

Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, empowerment, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation.

Conclusions

The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00403-9.

Nursing Students' Knowledge, Competence and Attitudes towards Vital Signs Monitoring during Clinical Practice

AIM AND OBJECTIVE

This study assessed the perceived knowledge and competence, and the attitude of Saudi nursing students towards vital signs monitoring for detecting patient deterioration during clinical rotation. It also examined the predictors of students' attitudes.

BACKGROUND

One of the most important uses of vital signs monitoring is the early detection of deterioration. Vital signs monitoring is one of the most frequently assigned tasks to students during clinical rotation. However, the attitudes of nursing students towards vital signs monitoring for detecting clinical deterioration remain unexplored.

DESIGN

Quantitative, cross-sectional design.

METHOD

A convenience sample of 529 baccalaureate nursing students in two universities in Saudi Arabia was surveyed using the V-scale from October 2019-December 2019. A multivariate multiple regression was implemented to examine the multivariate effect of the predictor variables on the five subscales of the V-scale. This study adhered to the STROBE checklist.

RESULTS

The overall attitudes of the students towards VS monitoring can be interpreted as poor to modest. The highest mean was reported in the subscale 'communication'. The subscales 'workload', 'key indicators' and 'technology' received low mean scores. The university, age, gender, academic year level and perceived knowledge had significant multivariate effects on the five subscales of the V-scale.

CONCLUSIONS

The Saudi nursing students had poor attitudes towards vital signs monitoring, specifically towards the use of technology in vital signs monitoring, the workload associated with vital signs monitoring and vital signs as key indicators of patient deterioration.

RELEVANCE TO CLINICAL PRACTICE

The findings reveal the need to improve the curricular content and training of nursing students regarding vital signs and the physiological indicators of clinical deterioration. This study also identified areas that require improvement to ensure positive attitudes among students.

Reflections on vital sign measurement in nursing practice

Physiological observations or vital sign monitoring is a fundamental tenet of nursing care within an acute care setting. Surveillance of vital signs with algorithmic early warning frameworks aids the nurse in monitoring for early symptoms of clinical deterioration. The nurse must be cognizant of the factors that can influence the vital sign measurements because the framework score is only as reliable as the data inserted. Vital sign technology has made significant progress in its ability to objectify nursing subjective assessments. Early scientists have struggled with its relationship with subjectivity, claiming it has no relevance in true science. Quantitative measurements, regardless of how objectively they were created or obtained, need a subjective lens to interpret and act on the results. The skill of "making" the vital signs can be easily taught or done with technology, but it is the "taking" of the data for analysis of truth and action that requires a higher level of expertise. This paper will examine the truth of vital sign methodology and monitoring to explore the question, "Is true objectivity in the nursing practice of vital sign measurement possible?" The truth in vital sign recognition through a subjective lens will also be explored to challenge the philosophical scientific claims that objective data are the absolute truth.

Clinical cues used by nurses to recognize changes in patients' clinical states: A systematic review

The aim of this systematic review was to examine the clinical cues used by acute care nurses to recognize changes in clinical states of adult medical and surgical patients that occurred as usual consequence of acute illness and treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist were followed. Four databases and reference lists of included studies were searched: from 1,049 studies, 38 were included. There were 26 subjective and 147 objective cues identified; only 6% of all cues described improvements in patients' clinical states. The most common clinical cues used were heart rate, blood pressure and temperature. Many studies (n = 31) focused on only one element of assessment, such as physiological stability, pain, or cognition. There was a paucity of studies detailing the complexity of acute care nurses' assessment practices as they would occur in clinical practice and a disproportionate focus on the objective assessment of deterioration. Studies are needed to understand the full breadth of cues acute care nurses use to recognize clinical change that includes both improvement and deterioration.

Physician awareness and attitudes regarding early warning score systems in mainland China: a cross-sectional study

INTRODUCTION

The purpose of the study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity, and attitude regarding these tools based on previously experienced unnoticed clinical deterioration (CDET).

METHODS

A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital.

RESULTS

There was a high level of physician awareness of the CDET problem. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S to be necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05).

CONCLUSION

Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.

National Early Warning Score: A survey of registered nurses' perceptions, experiences and barriers

AIMS & OBJECTIVES

To describe registered nurses' perceptions, experiences and barriers for using the National Early Warning Score in relation to their work experience and medical affiliation.

BACKGROUND

Indications of inconsistencies in adherence to the National Early Warning Score have emerged.

DESIGN

Web-based questionnaire study.

METHODS

The questionnaire was sent to 3,165 registered nurses working in somatic hospitals in the southern part of Sweden. Strengthening the Reporting of Observational Studies in Epidemiology was adhered.

RESULTS

Seventy-one per cent of the 1,044 respondents reported adherence to the National Early Warning Score guidelines recommended frequency of monitoring and 74% to the clinical response scale. The shorter the working experience, the higher the proportion of registered nurses who answered positively to the National Early Warning Score allowing them to better prioritise their care with short nursing experience. When categorising nurses according to their workplace's medical affiliation, adherence to the National Early Warning Score guidelines recommended frequency of monitoring was reported highest in surgery and orthopaedics (66%) and lowest in the cardiac high dependency unit (52%). Corresponding proportions of reported adherence to the clinical response scale were highest in orthopaedics (82%) and lowest in the cardiac high dependency unit (48%). Lack of response from the doctor was reported as one of the main reasons for not adhering to the National Early Warning Score by 50% of the registered nurse.

CONCLUSION

In general, registered nurses perceived the National Early Warning Score as a useful tool, supporting their gut feeling about an unstable patient. Barriers to the National Early Warning Score were found in doctors and the most experienced registered nurses, indicating the need for resources to be focused on the adherence of these members of the healthcare team.

RELEVANCE TO CLINICAL PRACTICE

In general, the registered nurses answered positively to the National Early Warning Score. We found indications that there is a need to focus resources on the adherence of the most experienced registered nurse and the doctors.

Novel model for predicting inpatient mortality after emergency admission to hospital in Singapore: retrospective observational study

OBJECTIVES

To identify risk factors for inpatient mortality after patients' emergency admission and to create a novel model predicting inpatient mortality risk.

DESIGN

This was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score.

SETTING

A single tertiary hospital in Singapore.

PARTICIPANTS

All adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes).

MAIN OUTCOME MEASURE

The primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs.

RESULTS

15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively.

CONCLUSION

We developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.

Improving student nurses' confidence in managing the acutely ill patient

AIM

the Acute Illness Management (AIM) course was introduced into NHS trusts across Greater Manchester in 2002/03 for registered nurses. In preparation for the transition from student to registered nurse, the AIM course was then included in the final year of the undergraduate nursing programme. The aim of this study was to evaluate the impact of the AIM course on student nurses' confidence in managing the acutely ill patient.

METHOD

a quantitative approach was adopted. Ethical approval was granted by the Research and Ethics committee at the University of Salford.

RESULTS

a total of 192 student nurses attended the AIM course; 94% of the students completed a pre-course questionnaire and 100% completed the post-course questionnaire.

CONCLUSION

the evidence suggests a significant increase in the student nurses' confidence in recognising, responding and managing an acutely ill patient following the one-day course.

Barriers and Enablers to Implementing the Children's Hospital Early Warning Score: A Pre- and Post-Implementation Qualitative Descriptive Study

PURPOSE

The purpose of this study was to identify and compare barriers and enablers to the implementation of the Children's Hospital Early Warning Score (CHEWS) on a pediatric inpatient unit pre- and post-implementation.

DESIGN AND METHODS

A qualitative descriptive design, guided by the Theoretical Domains Framework, was used to conduct semi-structured focus groups and individual interviews with nurses on a pediatric inpatient unit to identify barriers and enablers in the pre- and post- CHEWS implementation phases. Data were analyzed using a directed content analysis approach followed by inductive thematic analysis.

RESULTS

Two pre-implementation focus groups (N = 15) and 8 post-implementation individual interviews with nurses were conducted. We identified pre- and post- CHEWS implementation barriers related to clinical decision making, interprofessional relationships, the unit context, and negative emotions, and enablers related to quality of care and patient safety. The identified barriers and enablers to implementation were categorized within 13 TDF domains.

CONCLUSIONS

Our findings illustrate a range of barriers and enablers to CHEWS implementation during the pre- and post-implementation phases. Tailored strategies are needed to overcome barriers related to nurses' perceptions of CHEWS impeding clinical decision-making and interprofessional collaboration. By addressing the identified barriers, we can leverage nurses' motivations for using CHEWS to improve the quality of patient care and enhance patient safety.

PRACTICE IMPLICATIONS

The barriers and enablers identified in this study can be used to select implementation strategies to support the use of early warning systems in pediatric nursing practice.

Barriers and facilitators related to the implementation of a physiological track and trigger system: A systematic review of the qualitative evidence

Purpose

To identify the barriers to, and facilitators of, the implementation of physiological track and trigger systems (PTTSs), perceived by healthcare workers, through a systematic review of the extant qualitative literature.

Data sources

Searches were performed in PUBMED, CINAHL, PsycInfo, Embase and Web of Science. The reference lists of included studies were also screened.

Study selection

The electronic searches yielded 2727 papers. After removing duplicates, and further screening, a total of 10 papers were determined to meet the inclusion criteria and were reviewed.

Data extraction

A deductive content analysis approach was taken to organizing and analysing the data. A framework consisting of two overarching dimensions ('User-related changes required to implement PTTSs effectively' and 'Factors that affect user-related changes'), 5 themes (staff perceptions of PTTSs and patient safety, workflow adjustment, PTTS, implementation process and local context) and 14 sub themes was used to classify the barriers and facilitators to the implementation of PTTSs.

Results of data synthesis

Successful implementation of a PTTS must address the social context in which it is to be implemented by ensuring that the users believe that the system is effective and benefits patient care. The users must feel invested in the PTTS and its use must be supported by training to ensure that all healthcare workers, senior and junior, understand their role in using the system.

Conclusion

PTTSs can improve patient safety and quality of care. However, there is a need for a robust implementation strategy or the benefits of PTTSs will not be realized.

Chief physicians' attitudes towards early warning score systems in Switzerland: Results of a cross-sectional survey

RATIONALE, AIMS AND OBJECTIVES

Early warning score systems (EWS-S) have been shown to be valuable tools to recognize otherwise unnoticed clinical deterioration (CDET) of patients. They have been associated with fewer unplanned transfers to the intensive care unit (UTICU) and lower in-hospital mortality. Little is known about their current usage in Switzerland and about the attitudes towards such tools among chief physicians. We aimed to assess the use of EWS-S in Switzerland and the attitudes of chief physicians towards EWS-S depending on previously experienced CDET followed by UTICU, reanimation, or death.

METHODS

Chief physicians of medical and surgical departments from all acute care hospitals in Switzerland were asked to participate within a project that aims to develop recommendations for the use of EWS-S in Switzerland (n = 118). The explorative study assessed perceived CDET, which led to UTICU, reanimation, or death of a patient, the knowledge and usage about different EWS-S and attitudes towards EWS-S in a written questionnaire. Means and percentages were used, and differences were assessed with independent t tests, chi-square, or Fisher exact test, as appropriate.

RESULTS

Adverse events based on CDET were reported frequently, and awareness among chief physicians was high. Less than half of the chief physicians knew tools that systematically assess CDET with one-fifth of responders reporting using tools at their department. Previous experiences of UTICU, reanimation, or death after due to CDET were associated with more positive attitudes towards EWS-S.

CONCLUSIONS

Adverse events based on CDET of patients are frequent and the awareness of this problem is high among chief physicians. Positive attitudes were more common with previous experiences of adverse events due to CDET. Our results strengthen the argumentation that the recommendation and future implementation of EWS-S in Switzerland would be meaningful.

The nurse response to abnormal vital sign recording in the emergency department

AIMS AND OBJECTIVES

To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs.

BACKGROUND

Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses' roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care.

DESIGN

Observational, retrospective chart review.

METHODS

Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score.

RESULTS

About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation.

CONCLUSIONS

It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented.

RELEVANCE TO CLINICAL PRACTICE

To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.