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Nursin’ USA - The trouble with early warning signs

  • 36 Comments

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.

  • 36 Comments

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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