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Trusts fail to use early warning systems to identify deteriorating patients


Hospitals are not using early warning systems to identify deteriorating patients, despite evidence they can help reduce hospital death rates.

The National Patient Safety Agency recommends the scoring systems - which are used alongside patient observations - are used for all patients on acute wards.

The early warning score is something that has made a massive difference

But only 52% of acute ward nurses taking part in Nursing Times’s patient observation survey said nurses on their ward “always” used the alert systems and 15% said they were used “rarely” or “never”.

That is despite growing evidence the scoring systems can help reduce hospital mortality rates.

Exclusive analysis by Nursing Times of data collected for the Dr Foster Hospital Guide suggests there is a link between hospitals’ use of early warning systems and the number of preventable deaths after surgery.

The new “deaths after surgery” measure in the 2010 guide is based on incidents where a patient has died after a “failure to rescue”.

It includes patients who died with a secondary diagnosis such as internal bleeding, pneumonia or a blood clot.

The measure is thought to be nurse sensitive as it highlights cases where patients have deteriorated while being cared for on wards.

Nursing Times’s analysis shows that hospital trusts where 100% of acute patients had warning systems in place had a failure to rescue rate 3% below the NHS England average.

But, in hospitals where fewer than six out of 10 patients had the systems in place, the death after surgery rate was 24% higher than average.

In numbers

  • 10 - Number of trusts in our sample of 140 that used early warning systems for fewer than 60% of acute patients
  • 8% - Respondents who said procedures for acting on signs of deterioration were followed “rarely” or “never”
  • 87 - Number of trusts where all acute patients had early warning systems in place
  • 18% - Proportion of respondents who were not confident staff knew what to do when signs indicated a patient was deteriorating


Chelsea and Westminster Hospital Foundation Trust was one of two trusts that performed well on the failure to rescue measure.

Clinical nurse lead for surgery and medicine at the trust Holly Ashforth told Nursing Times that failure to rescue depended on a number of factors and that early warning systems gave ward staff confidence to flag up deterioration.

She said: “The early warning score is something that has made a massive difference.”

Head of the Florence Nightingale School of Nursing and Midwifery at King’s College Anne Marie Rafferty said the failure to rescue rate was “a good measure of the efficiency and effectiveness of a system to pull a patient back from a situation of danger”.

She said that it was a “very sensitive indicator for the quality of nursing observations” but “it is not just the individual nurse, it is the environment”.

Professor Rafferty said that the use of warning systems could indicate a ward that was concerned with safety in general and that the systems on their own would not necessarily make patients safe.

University Hospitals Birmingham Foundation Trust was one of four trusts with a “higher than expected” failure to rescue rate, according to Dr Foster.

Trust medical director Dave Rosser said: “The methodology for reaching their hypothetical figure is fundamentally flawed and misleading to the public.”

He said that certain patient groups had been wrongly included when the rate was calculated, which meant the trust scored worse than it otherwise would have.

Research by the National Nursing Research Unit says concerns that clinical coding skews the failure to rescue measure are unfounded. But warns against direct comparison between trusts.

The unit’s director Peter Griffiths, professor of health services research at the University of Southampton, said the traditional mortality rate metric primarily reflected the underlying conditions patients had when they were admitted.

He said the failure to rescue measure was an improvement on that measure because it focused specifically on conditions that were sensitive to the quality of hospital care.

His research found the failure to rescue metric reflected a number of factors, including levels of clinical staff.

“It is more about the culture, the systems that are in place and how teams work together,” he said.

Failure to rescue

Hospitals’ failure to rescue figures were published for the first time last year, by health analysis firm Dr Foster.

The indicator - also known as death after surgery, or death among patients with treatable complications - attempts to use routine hospital data to measure the quality of care for patients who are at a high risk of deterioration and death.

Deaths among this group of patients can, more often than among other patients, be avoided by good systems to identify and respond to deterioration following an operation - all linked to nursing.

The indicator is thought to be a better reflection of the quality of nursing care than many others, and is relatively easily produced by analysts.

It means the NHS is a step closer to routine measures that could be produced and used to either condemn or praise nurses about their skills and performance. Such measures could also be used by patients to decide which hospital to attend.


Readers' comments (11)

  • Observation skills and the EWS are great tools, enabling Staff Nurses to interpret patterns in the patients condition and act accordingly.

    The problem is, they are just tools, nothing more. It takes trained professionals to interpret them.

    This is where many wards are falling down, instead of hiring enough Staff Nurses to perform tasks like this, they expect HCA's to do it instead. HCA's are not trained professionals, it is as simple as that.

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  • on the ward where i work only trained staff carry out the observations now as some of the HCAs didn't feel they were able to interpret the ews. not only that they were looking at the machine and not the patient. i am happy to do the patients observations and always make time to do so even when we are short staffed. better to care for an acutely unwell patient first before a wash.not having a wash wont kill a patient but an arrest can

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  • there is far more to patient observation than measuring vital signs but do nurses still learn how to develop their observation skills or are many merely relying on untrained staff or instruments

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  • Anonymous | 25-Jan-2011 11:32 am I am glad to hear that is the case on your ward, I do so myself. However I am acutely aware that not every ward within my own trust does, with HCAs routinely carrying them out.

    And Anonymous | 25-Jan-2011 11:45 am, what a ridiculous statement, of course Nurses still learn observation skills! Vital signs and obs machines etc are important tools that form part of the process of patient observation and should not be dismissed as mere 'instruments' as long as they are used alongside a more complete observation of the patient and clinical judgement. The fact that increasing numbers of HCA's are doing observations and the fact that there are less Staff Nurses around to do them are down to short sighted and ridiculous management decisions, not Staff Nurses.

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  • Mike,


    'there is far more to patient observation than measuring vital signs but do nurses still learn how to develop their observation skills or are many merely relying on untrained staff or instruments'

    This is not a ridiculous statement at all because it is a question although I failed to put in a quesiton mark. I do not deem it a ridiculous question but extremely important in the light of all the current criticisms of patient care. emphasis on different aspects of training and what is important change with every new generation of nurses but hopefully the art and skill of clinical observation is just as good as it ever was.

    i confess that i am as guilty as the rest when it comes to writing comments as they are usually done in a rush so i tend to omit punctuation and capitalisation where it is not vital for the sense

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  • Anonymous | 25-Jan-2011 7:18 pm, well you can understand where the confusion came in then?

    It may not be a ridiculous question (as opposed to a statement), fair enough, however the rest of my comment still stands.

    There are many problems with current Nurse training which I won't get into here, but as you say 'the art and skill of clinical observation' is a constant basic.

    In light of many of the current criticisms of patient care, I always argue that the majority of this is down to lack of trained staff, ridiculous and dangerous Nurse/patient ratios, and moronic management decisions such as those I outlined above, rather than the skill/training of Nurses themselves.

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  • Same old loud do we need to play it?
    There is a wealth of research out there that proves the biggest danger to an acute patient is lack of RNs. End of.

    Dr Foster need to do the metrics around staff ratios and patient mortality. Most trusts fiddle the numbers with WTE and 100 bed days...anyone with a PIN can be included in WTE regardless of how much patient contact they have. I have a good friend in London who works in the ICU of a major teaching hospital. They run on bank staff. Recently a Band 8 had to come out of the office and onto the unit to work as an RN....was about as much use as a chocolate teapot. If you want to stay on the register, you should have to stay clinically up-to-date. Rant over.

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  • Totally agree with those who have rightly identified that the problem is RGN to patient ratios. You can have as many risk assessment tools, warning scores and outreach teams as you like, but patients do best when they’re physically cared for by qualified nurses.

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  • we have an early warning system in place in the trust where i work. its great at ward level it lets us know immediately that a patient is deteriorating and helps us to sort out this problem as quickly as possible. There are criteria whereby the doctor has to sign so we do not score anymore and these are very often in patients that have a poor prognosis or have a long term condition that is not responding to treatment as effectively as it could. However i find where this system falls is where not all departments use this valuable tool as they should be using it. because of the type of ward it is we have to take patients from accident and emergency, when you ask them what their ews score is they say they do not use it, i have talked to the matron about this and she assured me they did as it is trust policy, and she would talk to the relevant departments, but still it happens, and very often we get patients that are not really approriate to move because of their poor condition which could be avoided if only this was done properly

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  • Anonymous | 1-Feb-2011 5:29 am

    sounds as you are passing the buck instead of using good clinical skills and judgment to assess the patients' conditions. why does a doctor have to sign are the nurses not able to use their initiative and take responsibility for their patients?

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