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Nursin’ USA - The trouble with early warning signs

Nursing Times’ resident US nurse Sara Morgan is struggling to understand the point of early warning scores. Shouldn’t all good nurses already know their way around vital signs?

As an emergency room nurse by background and first love (and yes, I will be using ‘ER’ instead of ‘A&E’ for the duration of this post) I live and breathe vital signs (or ‘observations’, if you prefer). After years spent triaging patients, I’ve learned that you can tell a lot about a patient’s state just by talking to them, but you can’t make a final assessment until you know their vitals. 

There was the man who came into my ER one winter, smelling of alcohol and seeming just like many other homeless men who had used cheap wine to keep warm, until I checked his vitals and realised that he was slurring his words not because of his drinking, but because his core temperature was 32C. And then there was the woman with the history of migraines who came in with a headache.  Was she having another migraine? Or was it her blood pressure of 280/145 that was causing her headache? 

All of which makes me really frustrated with early warning scores, which I first encountered here in the UK. I understand the theory behind them — when enough of the vital signs are outside of the normal range, the EWS goes up, triggering a response from the nurse, HCA, or whoever records the vitals. 

My problem with the EWS is this:  why do nurses have to waste our time deriving a score from data that we already have to tell us what WE SHOULD ALREADY KNOW. That’s right — if a patient is going bad, the nurse should know from the vital signs themselves, not from a secondary score that is calculated afterwards. 

Knowledge gap?

Why would a patient with a blood pressure of 80/55, heart rate of 120, respirations of 26 and a temperature of 39 be stable, but the resulting EWS of something like 47,000 suddenly make the nurse think twice about the patient’s status? When I have asked this question of colleagues, the response that I usually get is that many vitals are taken by non-registered staff. Does that matter? 

Anyone who is collecting vital signs on patients should know when vital signs are abnormal and know what to do with that information. If there is some segment of the nursing workforce, trained or untrained, which is failing to notice deteriorating vitals, then is an additional box-ticking exercise suddenly going to make them pay attention?  

The wrong solution

The creation of the EWS score is a solution to the problem of healthcare staff failing to recognise deteriorating patients, but it is the wrong solution. First, it adds more work and documentation to the nurse’s already heavy load. Second, if we as nurses are not interpreting vital signs correctly, why would we be any better at crunching that data into a new number and then acting on that result any more appropriately than we had on the original vitals? 

And lastly, the EWS score completely ignores the subtleties of vital signs that make up the ‘art and science’ of nursing care.  An oxygen saturation of 90% might trigger a call to the doctor under the EWS system, but an experienced nurse will recognise that for particular patients, a COPD patient for example, 90% oxygen saturation is entirely appropriate. 

What about a stroke patient who is aphasic, but has a suddenly raised heart rate?  That heart rate might be the only indication that the patient is in pain, which is easily treated with prescribed medication, rather than taking time to chase down a junior doctor to tell her that the patient’s EWS has changed. 

Clearly, EWS scores were designed to keep our patients safe — a goal that we all aspire to. But if that is the only thing that lets a nurse or HCA know when there is a problem with a patient, then I think it’s time that we as a profession acknowledged that there is a problem with how we are trained to gather and interpret vital signs.  We need to solve the problem at its root — in our training — and not with a new box to fill out on a piece of documentation.

Readers' comments (36)

  • I agree entirely. So much is into schemes and systems and yet the true nurse (so I was told in my training in the 80s) looks at the patient as a whole from head to toe noticing vital signs, verbal and non verbal responses and then develops an instinct that is totally patient contact led and tells you straight away something is up. This instinctive reaction is often faster than filling in another form as mentioned in article above. Certain things trigger warnings and certain knowledge and logic makes sense of them. Are we now too cleve for basics. Is that what degree nursing does (oh and by the way I do have a degree but learned common sense first).

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  • Oh my goodness we have a sensible article on this site.

    You are 100% correct. The additional tick boxing makes matters worse. Patients become failure to rescue statistics when RN staffing is poor. Additional paperwork will never solve this problem.

    I was left as one RN to 25 medical patients the other day. My only help was a teenager. He was an untrained carer from some agency. He could not take vitals, blood sugars, or do any lifting due to a "bad back". We were the entire staff on that ward for 12 hours.

    Filled in the usual incident forms and called the chief nurse, matrons etc. Was told to "stop complaining". I finally demanded to speak to the chief exec. But he/she is refusing to communicate with me.

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  • It sounds like this EWS is a highly dangerous system and prone to error and precious loss of time in a critical situation in a busy clinical area where urgent treatment might be more appropriate for the patient than filling in more forms. It is each individual vital sign, including the visual appearance of the patient and other signs and symptoms that are the warning system not a statistic. Nurses, and others observing patients and measuring vital signs, are, or should be, well trained in and responsible for recognising any abnormalities and taking appropriate action. Why are nurses and trained HCAs in the UK never trusted to use their training, expertise, experience and intuition and do the job they have been trained for and know how to do best.

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  • What happened to the end of the bed test.
    Your patient is a whole being not just a urine output in an hour .
    many of those trained in the late 70's early 80's will be looking toward retirement in the next 5 - 10 years, we need to address the basic common sense short fall now
    Some of us will be patients and I for 1 want to be assured of a nurse who doesn't use a chart to determine whether or not I am sick

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  • I agree with the author, however as newly qualified nurse I do like the EWS (or MEWS). I've been trained on it as a student, however I have seen how it can lead to more work and as some of HCA's I work with do the vitals they just fill it in and do not think furthwer than that. When I do the vitals I look at the trend and the patient. I dod believe that with the culutre of getting sued/ struck off that we have a soviet era work mentality and that this will paralise us when we need to act.

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  • I absolutely agree. Nurses should be trained to be critical thinkers and problem solvers not number crunching computers. They should not need a MEWS chart to tell them that a patient is deteriorating. Anyone who is allowed to take observations should know the difference between normal and abnormal and the appropriate action to take.

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  • Excellent article. You might want to know that some of us practice the common sense you are discussing. We tick the boxes afterwards. As someone who primarily worked in Psychiatric facilities, similar issues can be seen in Mental Health settings both here and in the USA. Examples are the compulsory completing of the BPRS (brief psychiatric rating scale) in acute admissions wards and other settings. Experience, knowledge, and understanding can generally tell you that someone's score for agitation might be sky high BUT then again, they have spent a morning at the GP, followed by 2 hours waiting for a duty CPN and finally being admitted into a bay with a floridly psychotic patient. The BPRS might pick up stuff at the point of assessment which is totally irrelevant if not placed in context. I remember nurses who did excellent things like predict the risk of violence or suicide being pulled up at the Performance reviews for NOT having a BPRS assessment in each of the case notes for the patients they are looking after. Crazy, i dont think this is a UK failing, i think it is a failure of common sense. You do realise though, that there are layers of middle managers whose jobs are secure as long as these redundant processes and requirements are in place????

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  • I absolutely agree! The EWS isn't perfect (some trusts don't even have SATs as part of them) and it can never in any way shape or form be a replacement for good practice or Nursing intuition. However, I HAVE found it to be a useful tool when writing up or when my intuition and knowledge says that a patient is worsening, it provides a protocol that says a Doctor must come and assess the patient at a certain stage, it is this protocol that I have on occasion found use for and have used to force action out of otherwise indifferent medical staff. It is also a good indicator of vital trends in the patients condition, alongside other tools of course. It isn't perfect, but as long as it is used in context (and filled in correctly and consistently by other staff!) with other tools, then it can be useful.

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  • I agree entirely. So much is into schemes and systems and yet the true nurse (so I was told in my training in the 80s) looks at the patient as a whole from head to toe noticing vital signs, verbal and non verbal responses and then develops an instinct that is totally patient contact led and tells you straight away something is up. This instinctive reaction is often faster than filling in another form as mentioned in article above. Certain things trigger warnings and certain knowledge and logic makes sense of them. Are we now too cleve for basics. Is that what degree nursing does (oh and by the way I do have a degree but learned common sense first).

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  • In many ways I agree with the author, and her comments are thought provoking. However in this day and age where we are required to justify every action and reaction then the EWS/METS or MEWS aids this. In addition when phoning a Dr to attend to a patient it provides a more structured and robust format and can aid decision making. Unfortunately the old times are gone, and even the good clinical nurse with expertise in patient assessment who knows when there is a problem sometimes needs a tool like this to motivate others to act.

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  • At last a sensible American there is hope. Dont forget where EWS and so much of our 'advanced management theories' come from. Scores, assessments or tools are aids at best to good nursing.

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  • Excellent article!
    Summed up beautifully by the first paragraph of "the wrong solution" section. All registered nurses should be able recognise deterioration in physiological status.

    Once again I am asking the same question I have been asking since 1981; why do staff incapable of interpreting results STILL take and record patient's vital signs?

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  • We use the EWS at work, and I hate it. Sometimes (on nights especially), if I'm trying to get a doctor to come see a patient with deteriorating obs, all they are interested in is what the EWS is, and why, if the score is 0 or 1 (eg, a post op patient with a falling bp and rising pulse, but which is not yet triggering a score), why I am asking them to review the patient.

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  • To the author, a well respected article.

    The EWS is to assist HCA (Non trained)to report observsation recording which do not fall within the normal range. The Nurse need to be informed promptly. In doing so the Nurse can take the appropriate actions. However this is providing the HCA is sensible to report the findings.

    Unfortunately I have had experienced where some HCA do not report observations which are out of range. As a result I personally record the vital signs of each patient I nurse whilst on duty and by doing this I am able to act upon those obs which are out of range.

    I have been doing some reading on American Nursing Theory and as a trained UK Nurse I must say I have learnt alot and I certainly take it as a positive and try to apply it to my care delivery.

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  • I totally agree - i don't use early warning scores because i don't need to, i know what normal parameters are and i can interpret patients vital signs and think critically about their condition, past medical history etc (as other posters have written about COPD patients etc).
    However i do see their usefulness when untrained staff are taking vital signs as long as those staff are trained to use the scores properly.

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  • How correct you are, but we are so dependant upon non registered staff undertaking these skills and all too often they have absolutely no idea about the
    1. significance of what they are undertaking,
    2. how to undetake this properly, ie what you learn from holding the wrist to assess the pulse, not just the rate - similarly with the respirations
    3. The unreliability of relying on equipment,

    Some non reg have been brilliantly trained, others by just 'ticking the box.'

    As the RN is accountable, and patients lives are at stake, we train all of our own - and assess them individually both how to undertake this and how to use score tool, and reasses annually.

    We also ask they report ANY score to the RN

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  • I recently underwent major surgery. Knowing what is normal for my vital signs I was astounded to be told by a qualified nurse that I was well just because my vitals were within the normal range... hence feeling really poorly - bounding pulse, nausea, headache, wound site pain and extremely dizzy I was just about dragged from my bed to the treatment room by two auxillaries, under the instruction of the qualified nurse, and had a drain removed... without the qualified nurse present... I wonder if this is normal practice in post surgical care... being mental health trained my only experience of general nursing is when I am a patient... god forbid i have to suffer such an experience again...

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  • As a nurse trained in the 80's in the UK and further training in the US in 2000 I can see both sides.

    I have been back in the UK for 5 years working in acute areas.

    My experience in the US showed that the basic ADL's were provided by the nurses aids. Meds were dispensed by a computerised system and IV antibiotics came allready mixed. ECG's and Nebulisation was not done by the nurses on the ward. Cardiac patients had telemetry and CCU had a nurse sitting in front of all the monitors and would call the ward with any abnormalities.. There were many other proceedures not provided by the nurses on the ward itself.

    In the UK the ward nurses give all care and perform proceedures, Ecg's, nebulization, suction and cardiac patients are on monitors by the bed which the ward staff have to interpret also. Nurses calculate and mix IV's for administration and medication is in a large general trolley for the whole ward.

    Duties for UK nurses are overwhelming at times. HCA's record observations, but many do not know how to interpret the results. EWS and other scoring systems have therefore become a tool to aid in deteriorating patients being highlighted. Without this tool currently in place, many patients could be left to deteriorate until the trained nurse has time to check the obs. With HCA's knowing to report a higher score immediately, patients are reviewed quicker.

    Is this ideal??? NO.. It would be wonderfull if trained nurses had the time to provide appropriate care, while new staff nurses and other team members were mentored and experience passed on to them. There are not enough nurses.....

    At present with wards dangerously short staffed, high nurse-patient ratio's and higher admission rates, to remove the EWS and other scoring systems will lead to more patients left in beds deteriorating, only being discovered when the trained nurse has time to check the charts or someone passing sees a patient looking like they are about to crash.

    I read many articles about the best way to deliver care and most of them are great in principal... The only problem is putting them into practise.

    I dream for the days when there are enough experienced nurses to provide excellent patient care and able to mentor newer staff... I dream...
    Back to work now, probably to find another risk assessment chart thats oh, so much better than the last one.....

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  • I find it useful as it is a very definite trigger to contact the doctor. Previously they would ignore calls. Now we can bleep them and remind them it is trust policy for us to act on the EWS...

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  • I personally think that the use of the EWS is vital towards documentation, a way of recording.

    As a sudent nurse in my final year I clearly state at my uni we are taught to look at the patient as a whole,not just the EWS, and I certainly know if I have a problem from the obs alone and do not require the EWS to tell me.

    On the contrast having lived in the US, and attending emergancy department with a child, no treatment is given without first showing insurance card or cash. I wonder why the EWS is that bad? perhaps both side of the pond need to rethink?

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