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.
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.