Early Warning Score for Patients in Hospital Department Wards. Patients’ Safety and Staff Satisfaction Analysis.

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

FACULTY OF MEDICINE

DEPARTMENT OF ANAESTHESIOLOGY AND INTENSIVE CARE MEDICINE

Early Warning Score for Patients in Hospital Department Wards. Patients’ Safety and Staff Satisfaction Analysis.

Author: Shuhaib Saidu Mohamed Supervisor: Vilma Traškaitė – Juškevičienė Head of the clinic: prof. Dr. Andrius Macas

Kaunas - 2021

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TABLE OF CONTENTS

1.1 ABSTRACT/SUMMARY……….4

1.1 Aim………4

1.2 Objectives………..……….4

1.3 Methods………...…….……..4

1.4 Results………...………,…....4

1.5 Conclusion……….…………,……4

2.0 ACKNOWLEDGMENT………...5

3.0 CONFLICTS OF INTEREST………...5

4.0 ANNEXES……….6

4.1 PERMISSION OF THE ETHICS COMMITTEE……….6

4.2

Illustration 1- Early Warning Score Chart……….7

4.3 Anonymous online questionnaire 1- (Early Warning Score, Beginning.)………8

4.4 Anonymous online questionnaire 2- (Early Warning Score, Summary.)………..9

5.0 ABBREVIATIONS LIST………..………...15

6.0 TERMS……….16

7.0 INTRODUCTION………16

8.0 AIM AND OBJECTIVES………19

9.0 LITERATURE REVIEW………...20

10.0 RESEARCH METHODOLOGY…...25

10.1 Extraction of data

…...25

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10.2 Study limitations……….

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11.0 RESULTS………...29

12.0 DISCUSSION……….31

13.0 CONCLUSIONS & RECOMMENDATIONS………33

14.0 LITERATURE REFERENCES LIST………..35

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ABSTRACT / SUMMARY:

Aim: The aim of this study is to analyze the attitude of personnel towards Early Warning Score before and after its implementation in Kaunas clinics departments along with analysis of the main obstacles and improvements that need to be carried out for successful implementation through a systematic review of the extant qualitative literature.

Methods: Firstly, using PubMed database a thorough literature review was performed by the researchers, then staff impressions and satisfactions of Early Warning Score before and after the trial period were analyzed using questionnaires for staff members in implementing EWS is used and those responses were visualized by Tableau software.

Results: Our systematic literature review analyzed several scientific publications from different countries, most of them focused mainly on the importance of implementing early warning scores as a latest safety system in recognizing deteriorating patients. Some strains noted in this review: Is this EWS system beneficial or just escalates stress among the hospital staff, will this system be a useful or an unnecessary barrier in assessing patients, also many nurses fear that this will consume much of their time and increase the workload. But from all the incorporated observational studies in this review showed that EWS can gladly be considered as Physiological track and trigger systems (PTTS) which is a physiological warning system which have been developed for the use outside critical care areas with the objective of ensuring timely recognition of deteriorating patients.

Conclusion: This study figured that Early Warning Score is a reliable safety system which recognizes

and helps to manage deteriorating patients. From the analysis undertaken before and after

implementation of Early Warning Score in Kaunas clinics departments, most of the staff showed

exemplary response towards the EWS system to be implemented in wards as a main tool to predict

clinical outcome of hospitalized patients. A common warning system, focused mainly on regular vital

signs monitoring that could enhance the communication among senior doctors and nurses and allow

them to observe and evaluate patients at risk of possible deterioration.

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ACKNOWLEDGMENT:

I am ineffably indebted to my supervisor Vilma Traškaitė – Juškevičienė and hospital staff (all nurses who participated in this study) for the constant keep up and support in completing research on time.

I also acknowledge with a deep sense of reverence, my gratitude towards my wife Thahseena Abdul Rassak for the time you have taken to assist with tableau software.

CONFLICTS OF INTEREST:

There are no conflicts of interest.

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ANNEXES:

PERMISSION OF THE ETHICS COMMITTEE

Prior to commencing the study, an approval from the BioEthics Committee of Lietuvos Sveikatos Mokslų Universitetas Bioethikos Centras, number –BEC-MF-153, on 15/12/2020 was obtained to protect the author and participants.

Image 1 : PERMISSION OF THE ETHICS COMMITTEE

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Image 2 : Early Warning Score Chart

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Figure 1 : Anonymous online questionnaire 1- (Early Warning Score, Beginning.)

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Figure 2 : Anonymous online questionnaire 2- (Early Warning Score, Summary.)

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ABBREVIATIONS LIST:

1. AEs - Adverse Events

2. CEWS - Chelsea Early Warning Score 3. ES - Early Signs

4. ED - Emergency department 5. EWS - Early Warning Score 6. HIS - Hospital information system

7. RCPL - Royal College of Physicians, London 8. RRT- Rapid Response Teams

9. TTS - Track and Trigger System 10. SAE - Serious Adverse Event

11. SEWS - Standardized Early Warning Score 12. MET - Medical Emergency Team

13. MEWS - Modified Early Warning Score 14. NEWS - National Early Warning Score 15. NHS - National Health Service

16. PACU - Post-Anesthesia Care Unit

17. PTTS - Physiological Track and Trigger Systems

18. NZEWS - New Zealand Early Warning Score

19. VIEWS - VitalPAC Early Warning Score

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TERMS:

Physiological track and trigger systems (PTTS) – Physiological Warning systems have been developed for use outside critical care areas with the objective of ensuring timely recognition of deteriorating patients. PTTS track parameters of patients early in the course of possible deterioration based on routine observation and assessment of the physiological parameters and trigger a clinical response when a remarkable variation is noted with patients’ status.

INTRODUCTION:

While patient safety is planned to clinch the early recognition and management of worsening patients, the Early Warning Score (EWS) was developed in the 1990s which focused on improving patient outcomes chiefly in cram full hospital departments such as an emergency department.

However, it is still unclear how each nurse is individually affected by this system and what are their impressions and attitudes towards the EWS implementation in hospital department wards [1].

Monitoring patients in the anesthesia and intensive care unit, mainly in post-anesthesia care unit

(PACU) after each surgical intervention is very important [37, 38] in order to prevent possible

anesthesia and surgery related complications and adverse events from happening. Each and every

patient should be monitored and managed by experienced medical staff until stability in patients vital

signs is obtained. ‘During the stay in PACU there is a high chance that patients suffer from

complications like hypoxia, hypotension, hypertension, shock, bleeding, rhythm disturbances, nausea,

vomiting, and changes in consciousness’ [37]. Such scoring systems aids in evaluating high risk

patients and can be provided with sudden treatment, thereby improving survival. Introducing scoring

systems for immediate detection of the likely complications in PACU patients, helps to early

recognize deteriorating patients and evaluate their clinical status ensuring patients safety and prompt

response [39, 40]. This objective is well maintained by one of the scoring systems called Early

Warning Score (EWS) ( Figure 3 : Early warning score evaluation table ). EWS managed to recognize a

noteworthy proportion of patients who suffered adverse events like cardiac arrest, pulmonary

embolism, had disturbed physiological parameters for countless hours prior to the event, thereby

immediate medical attention was enhanced [2].

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18 It is clear that the purpose of rapid response teams (RRT) or medical emergency teams (MET) is to notify early signs of deterioration in patients who are hospitalized. Upon notifying immediately the deterioration may be able to be prevented and many studies have illustrated that most patients who suffer in hospital cardiac or respiratory arrest have had some worsening of vital signs or other clinical signs at least 6-8 hours prior the arrest. Serious adverse events (SAE) can be avoided by preventing human error by recognizing early warning signs of clinical and physiological worsening and responding accordingly [3].This led to the search for greater ways to identify clinical deterioration earlier. So many have tried to evolve “track and trigger '' systems where physiological parameters are monitored in order to observe trends showing clinical or physiological deterioration that levels assessment and intervention. Many recent researches are aiming to bring a constant tracking for several physiological parameters (physiological surveillance), but some more previous “early warning systems” (EWS) looked at several parameters cumulatively and attempted to fit them into a “score”

that would indicate deterioration and trigger a response. In the last decade, the use of EWS has been broadly suggested [1, 4] to be executed in acute care hospitals and multiplication of systems aroused.

EWS may be grouped as single parameter criteria, multiple parameters and aggregate weighted systems, the latter of which have become most common in the UK [5].

Nurses usually play a crucial role in recognizing physiologically deteriorating patients and reporting their observations to doctors so that prompt response and escalation of treatment could be ensured immediately. Most of the time there are very few experienced and highly qualified nurses on the ward and some inexperienced or temporary nurses tend to treat elderly and many severely unwell patients in hospital department wards especially during night time, this arises the problems with patient safety. For all the increasing technical civilizations in vital signs monitoring in the evolved world, problems with monitoring still continue.

All things considered, the EWS system is amply used in many European countries and appropriately executed in the clinical routine. Hence analyzing nurses’ satisfaction on implementing EWS in department wards because the attitude and reaction towards the EWS system would assist in proper care and prompt detection of deteriorating patients in hospital department wards.

The COVID-19 outbreak enhanced the need for urgent medical attention especially in emergency

departments, neurology departments, also in the main COVID-19 departments. Implementation of these

scoring systems like EWS may assist the nursing personnel, also we cannot avoid the possibilities that

19 some nurses may find these scoring systems not so comfortable, as it increases the workload, hence such a system is hard to appreciate during a pandemic. One of the main focuses of our research is to evaluate the perception of nurses towards the implementation of early warning scores.

In an attempt to systematize the EWS systems in hospitals, the British Royal College of Physicians recommended NEWS for the routine clinical assessment of all adult patients. A score is allocated to each of the following physiological observations: respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature and level of patient consciousness (

Image 2 : Early Warning Score Chart ).

An increase in the total score suggests that a patient’s condition has deteriorated. EWS education is productive for users, particularly nurses, in strengthening their knowledge and clinical performance, showing that vital sign recording and EWS calculations were enhanced. It is a useful tool for all the nurses which helps to identify when certain assistance is needed and what level of care should be provided for the particular patient.

Table-1 Clinical risk assessment by NEW score

Here our primary aim is to evaluate the attitude of personnel towards before and after implementation

of EWS in clinics department wards along with analysis of the main obstacles and improvements that

need to be carried out for successful implementation. Furthermore, the secondary aim is to evaluate the

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20 staff attitude and reaction, also to analyze nurses’ impressions and satisfaction of EWS before and after the trial period

AIM AND OBJECTIVES:

The aim of this study is to perform an analysis and literature review on the Early Warning Scores used in other hospitals in most advanced healthcare systems and to analyze the attitude of personnel towards Early Warning Score before and after implementation of it in Kaunas clinics departments along with analysis of the main obstacles and improvements that need to be carried out for successful implementation.

The objectives of the research are as follows:

1. To perform a literature review and analysis of Early Warning Scores used in other hospitals.

2. To analyze nurses' attitude and reaction upon the Early Warning Score system before and after implementation.

3. To analyze nurses’ impressions and satisfaction of Early Warning Score before and after the trial period.

4. To find out what are the main barriers regarding implementation of EWS and measures to overcome them.

LITERATURE REVIEW:

Identifying the deteriorating patient remains below the expected standard and has a major impact on

patients’ safety. In order to recognize abnormal physiological measurements and to lessen medical

mistakes by a simple scoring system, in 1997 in the UK the early warning score (EWS) was the first to

publish [7]. Across the UK these scores were calculated differently and not specifically and there were

many limitations upon using a variety of different scores across the National Health Service (NHS). In

order to standardize, the Royal College of Physicians (RCP) developed the National Early Warning

Score (NEWS), which was introduced in 2012 [23]. This is a bedside scoring system where nurses

monitor the vital signs and calculate a total score to seek medical attention from doctors and to identify

patient’s deterioration early.

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Using EWS is especially important in post-surgical patients as they are 1000 times probable to die in

30 days after surgical intervention than during surgery itself [45] this signifies the Early warning scores

system (EWSs) which offers a potential solution to the occurrence of adverse events (AE’s) and

accidental deaths in hospital patients. These tools recognize the probability of patients deteriorating,

which is often explained as death or admission to the intensive care unit (ICU). The EWS activates a

warning when a patient shows signs of deterioration, so that immediate treatment or care can be

summoned.

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22 Illustration -2

Patient monitoring guide used in the post-anesthesia care unit (PACU) in the patients who were followed-up

with Early Warning Scoring System (EWSs) (extracted for the present study using the references [41, 42, 43])

23 In the beginning EWS was implemented on paper-based observation sheets (

Image 2 : Early Warning Score Chart ), which can now be seen increasingly becoming part of electronic health record systems [8]. EWS system use is mandatory in hospitals in the United Kingdom as a standard of care by the National Institute for Health and Care Excellence [9]. Scarcity in providing proper care and attention to patients has been detailed among health care staff members [10]. Delay in reporting signs of worsening occurred within nurses in the UK because they did not use medical terms confidently [11]. Even if 70–80% of adverse events (AEs) in aggregated health‐care systems may result due to human error, organizational systems put up to the issue and the literature about early warning scores contribute remarkable solutions [12]. The presence of multicultural staff members in hospitals generates problems with handling critical care abilities. To overcome this issue a standardized monitoring tool is important. Reduction in nurses’ energy so called nurse burnout results in lack of motivation, emotionally exhausted and frustrated feelings leads to reduced work potency. Increased number of patients, too few medical staff members affect the patients care and safety, this shows an importance in implementing a standardized monitoring tool in hospital departments.

Over time the early warning score system established in the UK [13] has been modified (MEWS) and standardized so every hospital in the entire country could use a similar monitoring tool [14, 15, 16].

Led by the example of the UK, NEWS has been introduced to Norwegian healthcare practice as a part of the Norwegian Patient Safety Programme (Norwegian Ministry of Health & Care Services, 2016) following recommendations from the Royal College of Physicians, London (RCPL) [2]. Well recognized scores internationally used are the Modified Early Warning Score (MEWS) and VitalPAC Early Warning Score (VIEWS), both have been authenticated predictors of mortality in the course of hospitalization [17]. Early warning scores were also launched by solitary hospitals, namely Chelsea Early Warning Score (CEWS), introduced by the Chelsea and Westminster Hospital, UK [18]. The New Zealand early warning score (NZEWS) was evolved based on available components and clinical evidence, it appreciates the availability to use scoring systems in various hospital ward settings like acute tertiary medical and surgical wards, inpatient mental health units, a private surgical hospital, and small regional hospitals [22]. Induction of different track-and-trigger systems (TTS) dissimilarity aroused, which made the necessity for the adoption of a national system.

Independent validity of the NEWS unveiled [24], and observations showed that medical personnel

found NEWS as simple to use in daily practice, decrease in workload rather increased their potential to

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24 recognize worsening patients [25]. The UK National Health Service embraced the NEWS all over extensively.

A study of how ward-based staff use vital signs and the EWS to package physiological worsening successfully to verify successful referral to doctors. Throughout 2002, surveys and interviews were carried out using a grounded theory method, and a total of 44 participants were interviewed (30 nurses, 7 doctors and 7 health care support workers) to analyze the physiological deterioration [26].

Participants of the survey specified that those patients who are in need for urgent treatment could be referred to doctors by accurately measuring each vital signs on the EWS sheet, also it provided concise, unambiguous and precise means of communication among the hospital personnel.

Other research confirms these results. Nurses showed exemplary response and were satisfied with the early warning score system in providing patients clinical status immediately to an attending doctor.

[27]. In a questionnaire study, surgical ward nurses noticed NEWS helps them to more easily draw attention from doctors, hence patient safety is maintained. [28]. These generic prediction tools like early warning scores should be routinely used to ensure patient safety in all hospitals departments. Six physiological parameters are measured at the hospital department wards using EWS ( Figure 3 : Early warning score evaluation table ):

a) Respiratory rate (BPM) b) Oxygen saturations (%) c) Temperature (°C)

d) Systolic blood pressure (mmHg) e) Heart rate (BPM)

f) Level of consciousness

25 Figure 3 : Early warning score evaluation table

I. Systolic BP = systolic Blood pressure II. A,V,P,U = Alert, Verbal, Pain, Unresponsive

The early warning score sheet is mainly used in the hospital setting to monitor deterioration or improvement in patients' clinical status. The EWS sheet contains specific areas to record urine output and pain severity as well although these two are not part of the EWS. It is important to notify that the EWS cannot replace generic scoring systems such as the GCS or disease-specific systems.

Early warning score systems require consideration at the level of the individual, team, hospital and

policy [19]. Systems like early warning scores should act as conclusion support tools that strengthen

clinical decision making as resistant to restoring it. Just recording vital signs is not enough, patient

safety is dependent on nurses’ clinical judgment of deterioration [20]. The nursing personnel reported a

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26 greater potentiality to read the sheet and identify the deteriorating condition of the patient, after implementing the EWS system [21].

To summarize, the Early warning score will contribute to an increased level of monitoring and clinical assessment of patients with great precision in selecting patients at risk of clinical worsening. To find out deterioration and ensure patient safety, nurses use EWS system, however algorithms used in EWS sheet seems simple to follow but are relatively difficult for nurses due to heavy workloads and challenges to present the status of a patient to senior medical officers within allowed time frames. They highly depend on the scores calculated by the nursing personnel using EWS systems but should focus on observing algorithms in the proper way as well and to detect worsening much earlier, so that to make sure the patient safety is not compromised in any ways [35].

RESEARCH METHODOLOGY:

Extraction of data

Prior to commencing the study, an approval from the BioEthics Committee of Lietuvos Sveikatos Mokslų Universitetas Bioethikos Centras, number –BEC-MF-153, on 15/12/2020 was obtained (See

Image 1 : PERMISSION OF THE ETHICS COMMITTEE ). Numerous measures were employed for

selection of literature and various scientific articles available on the topic. A rational content analysis method was taken in arranging and examining the data. Primarily, screening of publications to match the titles, then evaluation of abstracts of publications to determine the acceptability for full text review.

The included studies evaluated vital signs monitoring in adult subjects. By the score used there were no limitations for study selection or the measured outcomes. A thorough evaluation of important aspects of patient safety and limitations in implementing the EWS system was carried out. Additionally, earlier issued scientific articles which were suitable to the thesis discussed here were collected from ScienceDirect & PubMed search engines, the keywords used were: “Early warning score”,

“Implementing early warning score”, “Patient safety AND early warning score system”, “Nurses

AND early warning score”.

27 While searching for literature on PubMed and ScienceDirect only papers issued in English (language), including only adults (age category) and humans (species) were filtered for the review. Around 1,372 publications were not identified initially, of which 17 publications were selected after filtering age category (adult), species (humans) for full text evaluation. These selected publications were studied in order to determine the suitability for addition in the analysis.

To categorize the difficulties and promoters to the implementation of EWS system all nurses who agreed to participate in the study were asked to fill two questionnaires: one before the implementation of the Early Warning Score and another after the study period of two months, which was a quantitative anonymous survey. We presented an anonymous online questionnaire on Google forms to the staff nurses. The main purpose of this questionnaire was to obtain opinion from the nursing and to analyze the nurse’s attitude and reaction towards implementing EWS in department wards, also to find out the barriers faced by nurses preventing EWS from successful implementation. At the end these collected responses from questionnaires were visualized using Tableau software.

Figure 4: Responses before the use of early warning score system

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28 Figure 5 : Impressions about early warning score system now

Figure 6 : Main problems encountered and observations

29 Process Flow:

Study limitations

Some factors exhibited poor effect on the quality and efficacy of the review; such limitations recognize weakness of the study:

• The review was carried out by an author, which escalates the risk for data missing and errors.

• Limited number of articles found during the search (within a 10 years’ time period).

• Some unanswered, dishonest, lack of personalized, false understating and interpreted responses from the questionnaires provided to each respondent anonymously.

• The open-ended questions responses were not so deep and satisfactory because of lack of time to respond to each question individually in their quality time.

• Questionnaire participation, although respondent’s anonymity was assured, not all nurses participated.

• Other healthcare professionals like doctors could have been included in the study. Although

this study mainly focuses on the nurses’ attitude up on the early warning score system.

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RESULTS:

Owing to many exhortations for prompt detection of deteriorating patients, the survey was carried out in three departments of hospital of Lithuanian university of health sciences Kaunas Clinics including ED, neurology department and COVID-19 main department. In this study we analyzed nurses’

impressions, attitude, reaction and satisfaction towards EWS before and after implementation in clinics department wards. Anonymous questionnaires aided for the survey (See Figure 1 : Anonymous online questionnaire 1- (Early Warning Score, Beginning.) & Figure 2 : Anonymous online questionnaire 2- (Early Warning Score, Summary.) ).

According to the survey conducted in the Lithuanian university of health sciences, Kaunas Clinics, all the responses were divided into two categories: before and after the implementation of the EWS system in Kaunas Clinics. There were 41 responses received out of which the emergency department was the section which demanded the need of deploying the EWS system followed by COVID-19 dedicated main ward as well as neurology COVID-19 department which showed their great interest in

implementing this system (See

Figure 4: Responses before the use of early warning score system .)

31 Section 1-Before the use of early warning score system

(

Figure 4: Responses before the use of early warning score system )

From the total responses aggregated in Kaunas Clinics, it was notable that ED admitted higher priority for the need of EWS deployment followed by the COVID-19 department with 31.7%. This depicts that out of 6 main departments, the emergency related section showed a greater necessity towards the system. Based on the responses collected before the use of EWS, approximately half of the responses (46.34%) completely supported the idea of EWS implementation in hospitals, however there still existed some respondents with minimal support. Along with that 51.2% of people showed impeccable support to the need of the EWS system in Kaunas clinic.

Almost 44% of medical practitioners believed that this system will aid improvement of services towards the patients’ health. Moreover, half of the responses (51.2%) were completely positive towards the necessity to provide training and essential aids for proper evaluation and scaling of parameters.

Majority of the responses showed willingness to recommend it to their loved ones which pointed out

their trust in this new technological advancement happening in the medical field. (See

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32 Figure 4: Responses before the use of early warning score system ).

Section2-Impressions about EWS systems now:

( Figure 5 : Impressions about early warning score system now )

The count of people who were moderately satisfied with this system increased which improved acceptance rating among hospital professionals. 29 out of 41 responses had an opinion that this EWS system will help to prevent a patient’s condition from deteriorating which directly points their mentality on its precision and accuracy. Around 44 percent supported that implementation of certain methods will definitely contribute to some duties towards the patient’s safety . (See Figure 5 : Impressions about early warning score system now).

More than half of the responses reinforced safety feelings over patients’ vital monitoring and around 56% were ready to recommend the EWS system to their relatives in Kaunas Clinics.

According to the analysis, the best place to fill the EWS chart is ‘At the patients’ bedside’ which is

followed by ‘The nursing station’. Proper documentation was necessary for better monitoring and

33 effective communication for handling a productive as well as dynamic patient - medical practitioner’s relationship.

From the questionnaire response it is clear that availability of vitals monitoring equipment to improve the patient's safety has a big role. Majority of people demanded mobile patient monitoring tool as the preferred version of equipment where only less than 10 percent preferred individual measures as an option. (See Figure 5 : Impressions about early warning score system now

Main problems encountered were inconvenient and inadequate patient monitoring equipment followed by excessive workload and lack of patient monitoring equipment but 2 out of 41 responses raised a problem that it was due to lack of involvement from the physicians. Lack of training prior to implementation of the EWS system, the COVID-19 outbreak affected the hospital staff members in aggregating the data into the EWS system, not so convenient with hospital information systems, also lack of monitoring equipment were the challenges faced to monitor patients adequately and conveniently. Observations and suggestions were carried out for the further development of the EWS system. (See Figure 6 : Main problems encountered and observations ).

DISCUSSION:

To investigate the literature a systematic review and narrative synthesis was conducted on Early warning score for patients in department wards and patient’s safety and staff satisfaction analysis. Nevertheless, there were no literature reviews which pointed precisely on the attitude of nurses towards before and after implementation of EWS in department wards along with analysis of the main obstacles and improvements that need to be carried out for successful implementation. It’s not enough just to record vital signs. Safety of patients depends on nurses’ clinical judgment of deterioration. Resources are required to confirm and assess MEWS/EWS systems in background [6].

The study showed findings that nurses have adopted an early warning score system (EWS) as a helpful

tool that can provide patient safety by helping nurses to identify and respond appropriately to patients

at risk of deterioration. “More time for nursing and communication”. “Reducing the nurse’s burden to

make more time to be with the patient”.

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34 Some nurses also recognized that just calculating the early warning score sheet will not be sufficient to provide enough patient centered care. “Look not only at the numbers, but also at the person’s own complaints”.

In order to gain more skills for observing, interpreting the patient status and thereby summoning a busy doctor needs proper training within the institution is mandatory. Proper teamwork was noticed among the doctors and nurses; it aids referral language and escalates coordination [44].

The EWS was helpful for contributing reliable evidence to support clinical perception [29]. ‘It does highlight patients that are actually deteriorating quicker than you would if you’d just got a normal chart’ [30]. The EWS was helpful in establishing trust to find patient deterioration and seek medical attention from doctors immediately, mostly for qualified recently employed and student nurses. ‘You see, with the early warning system you have got more ammunition, haven’t you...It provides what you need to get a doctor there, I think. It gives you...your full objective facts’ [29]. Nevertheless, this tool showed that it was an example of deskilling and expunging clinical judgment [29]. ‘We should be educating junior staff to look for more than just teaching them to use colors’ [30].

In identifying the deteriorating patients, early warning scores have become universal. Outstanding predictive value of early warning scores was confirmed by the literature review we performed during this research. It is important to notify that in the inpatient setting the early warning scores had influenced patient outcomes.

Also, it enabled nursing personnel to functionally communicate patients’ clinical status to doctors.

Thereby doctors can easily identify the severity of deterioration, make judgments on patients’ status, plan proper care, immediate diagnosis and treatment. Although, it is important to admit that they are more suitable in certain groups of patients and proper management is needed in elderly, pregnant, pediatric, palliative and head-injured communities [31]. This system appeared to escalate the possibility for false alarms and alarm fatigue. ‘EWS (physiological track and trigger systems - PTTS) has increased the number of interventions on patients including possibly unnecessary interventions’ [32].

The use of early warning scores outside their original limit is appreciable. Incompatible results are

shown while investigating the use of early warning scores as a pre-hospital triage tool. Well these

credits to a heterogeneous population in a pre-hospital setting. Whereas, a few reviews detail that the

common language of early warning scores enhance communication within healthcare professionals,

35 this is not consistently reflected in the response to the growth. Staff engagement and the reaction to poor scores are enhanced by proper training [31].

A remarkable limitation of early warning score systems is their intermittent character of manual data charting. It is clear that continuous automated sampling of SpO

is far better than manual recordings.

By early warning score system it cannot reflect physiologic patient state very well. Currently, in most of the areas early warning scores (EWS) rely on manual vital sign recordings. [33]. By choice, most patients would get an ICU way of continuous monitoring, but the bulkiness of the equipment in fact limits the patient’s mobility and impedes recovery. Certainly, when an ICU way of monitoring was accomplished on a department ward, only 16% of patients stayed connected in a 72-h period [34].

Hence, to manage the intermittent character of ongoing early warning score system, latest remote monitoring technologies have the ability, which are aided by wireless data transmission. Appearance of many devices assures to convey the advantages of continuous vital signs monitoring of patients in department wards. Whereas it appears natural that uninterrupted observation is safer than intermittent monitoring, hence there are not many supervised trials being performed for upcoming development this stays always a thrilling section [31]. A new inexperienced nurse could be in a dilemma that it is necessary now to call an occupied doctor, but by early warning score system it is so easy to calculate the score and interpret the observation thereby a doctor can be called without any further delay. This system aids nurses in making decisions and this facilitates faster diagnosing and proper treatment.

Responses from the questionnaires were impeccable, most of the responses support patient’s safety up on vital monitoring and nursing personnel were ready to recommend the EWS system to their relatives in Kaunas clinics, which showed nurses, trust in implementing such scoring system. “I support the idea and will be happy to encourage colleagues to EWS system”.

Not all respondents were positive to the survey, some nurses pointed, “The idea is very good, but every 2h to measure and 120/80, I don't see the point, but I'm not a doctor. Although if it is stable in any way, it should be monitored every 12 hours, but monitoring every 2 hours does not make much sense”, “lack of equipment in department wards, computer”, “need for this system in all departments”.

Also needed for nurses’ training in order to overcome the miscalculation of the early warning score and

to adequately detect or monitor deteriorating patients. “Staff needs to be trained and made aware of the

benefits of using this scale”. Need for strengthening skills is noted from the survey and the institution

plays a major role in it. Nursing personnel ability to interpret, observe and monitor the vital signs gets

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better only by experience. Upon implementing the EWS, the need for adjusted and adequate workload

for nurses in order to avoid nurses’ burnout. Respondents also stated the difficulty they might face due

to COVID-19 outbreak “Under the current workload due to the Covid-19 outbreak, there is a lack of

time to aggregate the data into the Early Monitoring Scale table”, “It is difficult to assess during a

pandemic when the focus is not on the early warning scale”. Hence, it’s hard to appreciate something

during a pandemic.

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CONCLUSIONS & RECOMMENDATIONS:

In conclusion, early warning score system is a safety system which significantly helps to recognize and manage deteriorating patients accordingly. It is much more important to execute early warning score system (EWS), as it aids in early intervention for deteriorating patients by providing an objective score based on patient's vital signs that nursing personnel could easily relay and senior doctors could easily understand. One must consider how the system is united with present work practices, and how to encourage assistance from the users. The lack of a proper implementation plan will signify that the likely assistance for patient safety, also quality of care of the EWS system will not be appreciated [36].

Our research figured that EWS can gladly be considered as PTTSs for the identification of early deteriorating patients in hospital department wards. Although, additional investigation is needed in future to find and solve barriers with implementation because from some responses we received from questionnaires showed shortage in time to fill up the EWS. "The more documents we fill out, the less time there will be for patients to be assigned and cared for”. Nurses’ need for few more parameters to be included in the EWS system, “The early warning handset should have accurate parameters (not cuts), more data (glycemia, belts, etc.)”. Furthermore some progress in hospital information system will aid the hospital staff members with medical documentation and proper communication among themselves. With proper HIS barriers with implementation of EWS can be solved. High workload with implementation of EWS raised by some nurses must be taken seriously in to account as they not only serve as a barrier in implementing EWS system but also can eventually lead to mental, physical and emotional exhaustion (burnout). With proper scheduled work hours, seminars on take of themselves, addressing your difficulties to respected ones on time one can beat the burnout. “Staff need to be trained and made aware of the benefits of using this scale”, before implementing such standardized monitoring tools, the need for proper education and training over the system is mandatory, this must be provided to all medical staff members on time.

But overall from the questionnaires provided to nurses’ in department wards, we concluded that EWS aids better communication among senior doctors and nurses, also decrease in workload rather escalate

their potential to recognize worsening patients (see

Final Master Thesis

38

Figure 4: Responses before the use of early warning score system ). Most of the staff showed exemplary

response towards EWS system to get implemented in wards as a main tool to predict clinical outcome

at the department wards. The above-mentioned barriers and measures to overcome them in

implementing the EWS system need to be properly followed and further studies must be carried out to

establish such a standardized monitoring tool, thereby enhancing nurse’s satisfaction and patient safety.

39

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