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Langkjaer CS, Bundgaard K, Bunkenborg G, Nielsen PB, Iversen KK, Bestle MH, Bove DG. How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice: A fieldwork study. J Adv Nurs 2023; 79:789-797. [PMID: 36541263 PMCID: PMC10107488 DOI: 10.1111/jan.15547] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Caroline S Langkjaer
- Department of Emergency Medicine, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Karin Bundgaard
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Neuro-, Head- and Orthopaedic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, Nursing, Health Faculty, Aarhus University, Aarhus C, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Copenhagen University Hospital - Holbaek, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense C, Denmark
| | - Pernille B Nielsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Dorthe G Bove
- University College Absalon, Centre for Nursing, Roskilde, Denmark
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Nielsen PB, Langkjær CS, Schultz M, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle MH, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Clinical assessment as a part of an early warning score—a Danish cluster-randomised, multicentre study of an individual early warning score. THE LANCET DIGITAL HEALTH 2022; 4:e497-e506. [DOI: 10.1016/s2589-7500(22)00067-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/02/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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Mølgaard RR, Jørgensen L, Christensen EF, Grønkjaer M, Voldbjerg SL. Ambivalence in nurses' use of the early warning score: A focussed ethnography in a hospital setting. J Adv Nurs 2021; 78:1461-1472. [PMID: 34841561 DOI: 10.1111/jan.15118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/12/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
AIM This study describes and explores the influences in registered nurses' use of early warning scores to support clinical decisions in a hospital setting. DESIGN A focussed ethnography allowed for the investigation of registered nurses' clinical practices in two wards in a Danish University Hospital. The study adhered to the 'Standards for Reporting Qualitative Research'. METHODS Participant observation and ethnographic interviews were conducted from March 2019 to August 2019. Ten registered nurses were observed and interviewed, and four physicians were interviewed. Data were analysed using LeCompte and Schensul's ethnographic analysis. FINDINGS The findings show the registered nurses' ambivalence towards the early warning score as a decision support system. Early warning score monitoring created a space for registered nurses to identify and initiate optimized care. However, when early warning scores contradicted registered nurses' clinical judgments, the latter were given priority in decisions even though elevated scores were not always accounted for in the situation. Moreover, we found unspoken expectations in the collaboration between physicians and registered nurses, which influenced the registered nurses' workloads and decisions regarding early warning scores. CONCLUSION Registered nurses' clinical judgment is essential to clinical decisions on the care and safety of patients if used combined with the early warning score. Interprofessional collaboration between registered nurses and physicians about the early warning score is challenged. Future research may address this challenge to explore how it should be operated as a collaboration tool. IMPACT The study adds knowledge to the evidence base of registered nurses' use of early warning score and the advantages and challenges associated with the use of these scoring systems. The study may provide valuable knowledge for the future development of policies or implementation strategies.
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Affiliation(s)
- Rikke R Mølgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
| | - Lone Jørgensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Clinic for Surgery and Cancer Treatment, Aalborg University Hospital, Aalborg, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Center for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Grønkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Siri L Voldbjerg
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Department of Nursing, University College of Northern Denmark, Hjorring, Denmark
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Wireklint SC, Elmqvist C, Göransson KE. An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study. Scand J Trauma Resusc Emerg Med 2021; 29:89. [PMID: 34217351 PMCID: PMC8254961 DOI: 10.1186/s13049-021-00905-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 06/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys. METHODS In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26. RESULTS Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage. CONCLUSION This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.
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Affiliation(s)
- Sara C Wireklint
- Emergency Department and Department of Research and Development, Region Kronoberg, Department of Health and Caring Sciences and Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, FoU Kronoberg, Sigfridsvägen 5, S-352 57, Växjö, Sweden.
| | - Carina Elmqvist
- Department of Research and Development, Region Kronoberg and Centre of Interprofessional Collaboration within Emergency Care (CICE) at the Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Katarina E Göransson
- Department of Medicine Solna, Karolinska Institutet and Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
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Nielsen PB, Schultz M, Langkjaer CS, Kodal AM, Pedersen NE, Petersen JA, Lange T, Arvig MD, Meyhoff CS, Bestle M, Hølge-Hazelton B, Bunkenborg G, Lippert A, Andersen O, Rasmussen LS, Iversen KK. Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS). BMJ Open 2020; 10:e033676. [PMID: 31915173 PMCID: PMC6955532 DOI: 10.1136/bmjopen-2019-033676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER NCT03690128.
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Affiliation(s)
- Pernille B Nielsen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Martin Schultz
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Anne Marie Kodal
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
| | - Niels Egholm Pedersen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John Asger Petersen
- Department of Day Surgery, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Sahlholt Meyhoff
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Bestle
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bibi Hølge-Hazelton
- Research Support Unit, Zealand University Hospital Roskilde, Roskilde, Denmark
- Department of Regional Studies, University of Southern Denmark, Odense, Denmark
| | - Gitte Bunkenborg
- Department of Anesthesiology, Holbaek Hospital, Holbaek, Denmark
| | - Anne Lippert
- Copenhagen Academy for Medical Education and Simulation, Herlev, Denmark
| | - Ove Andersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Emergency Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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