Early warning scores: effective use
A trust has lowered its mortality ratio by improving compliance in EWS monitoring
In this article…
- Monitoring staff use of early warning scores and action taken
- Developing innovative solutions to benefit patient care
Sue Smith is director of nursing and patient safety, North Tees and Hartlepool NHS Trust
Smith S (2011) Early warning scores: effective use. Nursing Times; 107: 3, early on-line publication.
In June 2008, North Tees and Hartlepool Trust signed up to Patient Safety First. Our objectives were to put patients first and to develop a culture of patient safety. We implemented the intervention discussed here with the aim of preventing harm and reducing in-hospital cardiac arrest and mortality through earlier recognition and treatment of deteriorating patients.
There is evidence that acute illness is exacerbated by “failure to act” on recognised changes (Hillman et al, 2001). Analysis of serious patient safety incidents revealed that 11% of deaths were related to “deterioration not recognised or not acted upon” (NPSA, 2007). Points where the process can fail include: not taking observations, not recognising early signs of deterioration, not communicating observations causing concern and not responding to concerns appropriately (NPSA, 2007). We focused on improving all these areas.
Keywords: Deterioration, Patient safety, Early warning scores
- This article has been double-blind peer reviewed
Early warning scores (EWS) rate individual patients’ risk of serious deterioration. The system is derived from four physiological readings and observing patients’ levels of consciousness. Although the trust introduced EWS in 2007, there had been no formal audit or associated training.
In November 2008, we started to use the Global Trigger Tool (GTT) (Griffin and Resar, 2009) to review the clinical records of recently discharged patients on a weekly basis. This showed that nursing and medical staff could improve management of EWS.
In February 2009, we carried out a baseline audit to aid our understanding of areas of best practice and those requiring improvement. Then, we took steps to increase staff knowledge, skills and communication related to EWS.
Early warning scores and subsequent action taken by nursing and medical staff are monitored through a monthly quality review panel consisting of the director of nursing and the senior nursing team. Weekly reviews of EWS were undertaken in specific areas, supported by training from critical care educators. The trust has also introduced clear escalation processes that have further supported improvement, and we conduct a quarterly trust-wide audit to show the impact of this work.
Nurses have developed innovative solutions to improve the management of deteriorating patients. For instance, nurses on medical and orthopaedic wards stop the clock every four hours to conduct observations. EWSs then go on a ward board and medical colleagues join the nurses to do a board round. Decisions are made every four hours, which helps clinical teams act promptly and appropriately.
To monitor patient perceptions of care, we ask them to rate the support they have received. This means they are assessing us based on their confidence in our nurses.
The May 2009 audit showed significant improvements in all criteria assessed (Table 1). This reflects the commitment of our medical and nursing staff to work together to improve every aspect of patient care and safety.
The work has continued to develop. Our mortality ratio is now the lowest in the North East and a positive outlier nationally, whereas it was the highest two years ago and a negative outlier nationally; management of the deteriorating patient has significantly contributed to this improvement. We now do a full root-cause analysis of every cardiac arrest which includes looking at what happened in the 48 hours prior to the arrest. Over the last 6 months, only one patient who had a cardiac arrest experienced a deterioration of their observations in the time leading up to the arrest.
Griffin FA, Resar RK (2009) IHI Global Trigger Tool for Measuring Adverse Events. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement.
Hillman KM et al (2001) Antecedents to hospital deaths. Internal Medicine Journal; 31: 6, 343-348.
National Patient Safety Agency (2007) Safer Care for the Acutely Ill Patient: learning from serious incidents. London: NPSA.
National Patient Safety Agency (2007) Recognising and Responding Appropriately to Early Signs ofDeterioration in Hospitalised Patients. London: NPSA.