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Can adapted EWS improve response to deterioration?

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A deteriorating recognition group reviews monitoring tools, compliance and training needs


In this article…

  • Why Early Warning System (EWS) are used to identify deteriorating patients
  • Using audit to evaluate and improve clinical practice
  • How to adapt an EWS to improve detection of deterioration
  • How to use situation, background, assessment and recommendation (SBAR) tool to complement the EWS
  • Use a training programme to implement change



Phil Jevon is resuscitation officer and clinical skills lead; Phao Hewitson is patient safety officer; Elaine Walton is resuscitation officer; Tracie Wilson is improvement and innovation manager; Carol France is professional development manager; all at Manor Hospital, Walsall, West Midlands.


Phil Jevon is resuscitation officer and clinical skills lead; Phao Hewitson is patient safety officer; Elaine Walton is resuscitation officer; Tracie Wilson is improvement and innovation manager; Carol France is professional development manager; all at Manor Hospital, Walsall, West Midlands.


Jevon P et al (2011) Can adapted EWS improve response to deterioration? Nursing Times; 107: 3, early on-line publication.

All nurses must ensure deteriorating patients are identified early, and a timely and effective response is implemented.

This article discusses the approach taken at Walsall Manor Hospital where a new early warning system and staff training programme to help prevent avoidable cardiac arrests.

Keywords: Deteriorating patient, Early warning system,  Response

  • This article has been double-blind peer reviewed


Acutely ill hospital patients sometimes receive suboptimal care because clinical staff fail to recognise deterioration or or to act on it quickly (National Institute for Health and Clinical Excellence, 2007).

Guidance from NICE and the National Safety Patient Agency stressed the importance of introducing systems to recognise deteriorating patients early, and to instigate an appropriate response (NICE, 2007; NPSA, 2007a; 2007b). This is also a key component of the Patient Safety First campaign (

In 2009, our board approved Safe in Our Hands – the trust’s approach to incorporating Patient Safety First’s interventions into its own patient safety strategy. This included work already started on reducing harm from deterioration, established in response to an earlier NPSA report (2007a).

Cardiopulmonary arrest in hospital

In the UK, only 17% of patients who have a cardiopulmonary arrest survive and go on to to be discharged from hospital (Nolan et al, 2005). Most of those who survive have had a monitored and witnessed ventricular fibrillation (VF) arrest, caused by primary myocardial ischaemia (Resuscitation Council UK, 2006). Survival to discharge rates for patients who receive prompt and effective defibrillation after a VF arrest can be as high as 42% (Gwinnutt et al, 2000).

However, most in-hospital cardiopulmonary arrests are caused by asystole or pulseless electrical activity, both of which are non-shockable rhythms associated with poor outcomes (Nolan et al, 2005). These arrests are usually neither sudden nor unpredictable, but the final stage of progressive deterioration of the presenting illness, involving hypoxia and hypotension (RCUK, 2006). These patients rarely survive to discharge and the aim should be to prevent cardiac arrest (Gwinnutt, 2006).

Recognising and effectively treating patients at risk of cardiopulmonary arrest could therefore prevent some cardiac arrests, deaths and unanticipated intensive care admissions (Nolan et al, 2005).

Early warning systems

Physiological deterioration precedes critical illness (Goldhill et al, 2005; Kause et al, 2004), and effective early warning systems (EWS) need to be in place to recognise the deteriorating patient (NICE, 2007).

The Department of Health recommends EWS and critical care outreach services are implemented throughout the UK (DH, 2000). However, the effectiveness of EWS has been questioned. If they do not have the appropriate sensitivity and specificity to reduce errors associated with documentation and scoring, they will fail to identify patients who need additional care and could increase workload unnecessarily (Cuthbertson and Smith, 2007). Hillman et al (2005) found that most deteriorating patients were not detected until within 15 minutes of a cardiopulmonary arrest, death or admission to ICU. Other studies have shown that staff calculations of EWS scores can be inaccurate (Prytherch et al, 2006; Smith and Oakley, 2006).

The NPSA analysed 576 deaths reported to its National Reporting and Learning System (NRLS) over a one-year period. More than 11% of these deaths related to patient deterioration which was not recognised or acted upon (NPSA, 2007a). Use of EWS needs to be reassessed, ensuring a structured, scientific approach to their development and evaluation (Cuthbertson and Smith, 2007).

Deterioration recognition group

The NPSA recommended all acute trusts set up deterioration recognition groups (DRGs) to lead efforts to improve the safety of patients vulnerable to deterioration (NPSA, 2007a or b?). The initial responsibilities of Walsall Manor Hospital’s DRG were to:

  • Review the current patient monitoring tools used at the trust;
  • Undertake a baseline assessment of compliance with the EWS within the trust;
  • Review NPSA-recommended tools;
  • Undertake a training needs analysis.

An audit of the EWS charts used at the hospital revealed that:

  • Vital signs were not always recorded;
  • Documents were poorly labelled;
  • The frequency of vital signs monitoring was not planned;
  • Abnormal measurements were not always acted upon;
  • Patient ‘norms’ were poorly documented;
  • Escalation guidance was missing;
  • The system was not appropriate for all patients, such as those for whom a high EWS was normal, for example, patients with chronic respiratory illness.

Introducing a new EWS

The EWS at the time used a numerical scoring system to trigger a response to a deteriorating patient. The audit revealed the chart was complicated, and the scoring system was difficult to accurately apply, so alternative systems were explored. Luton and Dunstable Hospital developed a chart with a red, amber, green (RAG) system for identifying escalating abnormal observations. Using the RAG model, along with the audit findings and NICE guidance, we produced a new chart which included:

  • A RAG system;
  • Escalation protocol;
  • Prescription for frequency of monitoring (minimum twice daily);
  • Exception notation for patients who trigger criteria due to chronic illness;
  • Signature for recording escalation.

After testing the chart we used a rapid improvement cycle to implement it. These cycles accelerate the delivery of projects by applying focused principles of change within a defined structure. This is usually a PDSA (plan, do, study, act) framework which involves making a small change in a controlled environment. This allows for fast testing to identify whether changes are effective. Cycles are assessed after 90 days to establish whether the project delivered its objectives, or if any notable deviations from the proposed changes were seen.

Staff training

The resuscitation officers developed competency-based in-house training on recognising and responding to the deteriorating patient. This is aimed at all nurses and healthcare assistants, and complies with DH (2008 [or 2009?]) and NICE (2007) guidance. Its key objectives are to reinforce the RCUK’s approach to assessing and treating acutely ill patients and the effective, timely and seamless “chain of response” (NICE, 2007), and enable staff to:

  • Recognise and interpret abnormal values;
  • Assess and institute clinical intervention in a timely manner;
  • Recognise when a higher level of assistance is required;
  • Convey the urgency of the situation.

Training started in January 2009, provided by trust resuscitation officers. It lasts 2.5 hours and is given to groups of six. The critical outreach team also gives one-to-one training in clinical areas and on annual updates, and an e-learning course is currently being developed.

The new EWS chart were introduced on the course and in mandatory updates, and participants were also taught how to use SBAR (Box 1). The NPSA’s Foresight Training Resource Pack was used to help nurses identify situations when patient safety incidents are likely, and how to reduce or prevent these (NPSA, 2008).


Box 1. SBAR

S - Situation. A concise statement of the problem.

B - Background. Information related to the situation.

A - Assessment. Analysis and considerations of the options.

R - Recommendation. Action requested or recommended.

Walsall Manor Hospital uses a modified SBAR tool as a structured way of communicating information that needs escalating.


The new EWS chart is now used across the hospital. The colour coding helps staff identify when and who to contact in different situations and the simplified, concise escalation process and SBAR has been well received. The chart allows staff to clearly document escalation and review interventions. We will be using the Patient Safety First extranet to track changes made to practice against audit results, such as those on the number of cardiac arrests, rapid response, and critical care outreach calls. We anticipate the EWS will lead to earlier responses to deteriorating patients, and a reduction in cardiac arrest calls.  

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