Jan 11, 2021
Nurses implement early warning system to detect patient deterioration
- Late recognition of patient deterioration is not an uncommon problem among health-care organizations; technology such as the National Early Warning Score (NEWS) can help.
- Nurses are encouraged to not simply focus on one NEWS result, but also monitor trends in scores and incorporate related assessment data in their decision-making.
- Less experienced nurses felt the NEWS gave them increased confidence; nurse leaders said the NEWS helped them in decision-making and discharge planning.
A variety of early warning scoring (EWS) systems have been developed with the aim of helping health-care practitioners detect patients at risk for deterioration, guide interventions, and prompt timely communication among members of the health-care team. In this article, we look at the methodology that we applied in implementing one system in our health-care alliance of four small community hospitals.
Nursing survey and chart audits
The primary impetus for implementing an EWS system within the Huron Perth Healthcare Alliance stemmed from discussions on how to decrease the number of unexpected admissions to the ICU from our inpatient units. A root cause analysis was performed, primarily composed of a nursing survey and chart audits of patients emergently transferred from inpatient units to the ICU.
The survey responses from more than 100 nurses indicated that they were not always confident in their ability to recognize deterioration in its earliest stages, critically think to plan interventions such as repeat assessments, and clearly communicate their concerns to the most responsible physician in a timely manner.
Chart audits of nursing documentation from unexpected ICU admissions showed that many times early signs of deterioration, as indicated by vital signs and other assessment data, were either not recognized or not acted upon. Improvements to nursing documentation were needed to accurately reflect both the nursing care provided and physician communication that had occurred in order to prevent the appearance of failure to rescue.
Recognition and prevention of deterioration
A literature review demonstrated that the late recognition of deterioration was not an uncommon problem among other health-care organizations. Thus, we contacted other hospitals in Ontario to see what solutions they had implemented to address recognition and prevention of further deterioration. Of those that responded, many of the larger centres use resources such as critical care outreach teams in the event of suspected patient deterioration, while the smaller community hospitals had yet to find a solution and did not have the resources to support the same type of outreach program.
The goal was to improve critical thinking in regard to the interpretation of patient assessment data in conjunction with trends in the EWS system.
To address our concerns, we initially began researching tools related solely to sepsis detection, as many of our unexpected ICU admissions appeared to be related to sepsis progression. However, research supporting the use of an EWS system for early detection and treatment of all types of deterioration was compelling. We decided to focus our efforts on selecting a screening tool that detected the early signs of patient deterioration from all causes (not only related to sepsis) and helped nurses plan escalation of care, reassessment frequency, and timely and concise communication with the physician.
The goal of implementing an EWS system was not to improve competence in patient assessment, but rather to improve critical thinking in regard to the interpretation of patient assessment data in conjunction with trends in the EWS system. In addition, we hoped to improve collaboration and communication with physicians while decreasing the appearance of failure to rescue, hospital lengths of stay related to sepsis, and unexpected admissions to the ICU.
National Early Warning Score
In December 2016, after successfully proposing the idea to our physician champions and our alliance’s leadership, we started planning the integration of the National Early Warning Score (NEWS) into the workflow of our clinical nurses. The NEWS is a validated tool, developed in the United Kingdom, which uses seven physiological parameters that nurses are already routinely assessing during patient care, to identify early stages of deterioration and trigger appropriate responses.
Assessment findings for each of these seven parameters are assigned a score from 0 to 3, based on how far they deviate from “normal” values. The higher the NEWS, the higher the potential for deterioration. To account for individual patients’ “normal” values, nurses are encouraged to monitor trends in scores and incorporate related assessment data in their decision-making rather than focus on one single NEWS result.
In cases where registered practical nurses (RPNs) are caring for patients whose NEWS starts to rise, the RPN is to consult with the team leader or other experienced registered nurses (RNs) to discuss appropriate next steps and determine whether some or all aspects of nursing care should be transferred to an RN. It’s also important to note that we required nurses to enter a brief comment in the vital sign intervention screen, detailing how they intended to follow up with the score, or the rationale/reason if they did not feel that followup was necessary.
Several articles reviewing the use of EWS noted that errors in obtaining a score are more likely to occur when nurses calculate the scores themselves. In order to ensure accurate calculation of the score, we worked closely with our information technology (IT) colleagues to enable the NEWS to be auto-populated into our Meditech electronic documentation system once nurses had entered the assessment data for each of the seven physiological parameters. In addition, depending on the scores, IT designed an “alert” pop-up that recommends followup interventions, prompts communication with other members of the health-care team, and suggests reassessment timelines.
Blended learning approach
A blended learning approach was developed to provide education prior to implementation. Learners first completed an e-learning portion that provided an in-depth review of sepsis pathophysiology, the NEWS tool, and the seven physiological parameters used to obtain a score. Once learners completed the e-learning, they attended a paid two-hour in-class session aimed at developing critical thinking and interpreting the NEWS totals.
Using realistic patient scenarios, nurses were able to practise using both clinical assessment findings and trends in NEWS totals when planning escalation of care, interventions, and reassessments. Anecdotally, many nurses confided that they were skeptical of the NEWS’s benefits until they had the opportunity to participate in the in-class education sessions and practise using NEWS with real patient scenarios. To support nurses post implementation, laminated resources were placed at every bedside. During the first weeks after going live, we provided in-the-moment coaching and support to nurses.
Nursing leadership provided implementation support by securing hospital foundation funds to cover wages for the required education and by ensuring staff attendance at the education sessions. In addition, they are asked to follow up with process compliance issues post implementation upon request.
In August 2018, we implemented a successful one-month NEWS trial on one of our inpatient units, and continued implementing the NEWS one unit at a time and every few months thereafter. By June 2019 we had implemented NEWS on all intended inpatient units within our four hospital sites.
Evaluation of the program
In order to evaluate the program’s success and identify opportunities for improvement, we engaged our decision support and quality improvement departments to gather meaningful quantitative data such as sepsis rates, lengths of stay in hospital, and the number of unexpected admissions to the ICU.
It has been challenging to demonstrate the NEWS’s overall effect on the length of stays for patients with sepsis owing to the occasional case in which a patient with significant comorbidities requires a stay of one month or longer. However, we have been able to show that post implementation, our unexpected ICU admissions (2019–2020) have decreased from an average of 5.2 to 4.3 per month. Through individual chart audits we were able to determine that the majority of these patients deteriorated suddenly without triggering increased NEWS prior to deterioration, therefore not allowing for early detection and intervention.
Subjectively, a number of our less experienced nurses have reported that the NEWS has given them an increased sense of confidence in detecting and managing the early signs of patient deterioration. We also found that the timeliness and quality of nurses’ documentation have improved dramatically where instances of potential and actual patient deterioration exist, thus addressing the concern of the appearance of failure to rescue. Unit team leaders have reported that because they are able to see all current NEWS totals for every patient in their unit, the NEWS has aided them in decision-making regarding delegation of patient assignments and discharge planning.
During the first weeks after going live, we provided in-the-moment coaching and support to nurses.
Physician receptivity and impact on patient care
Although we engaged the physician groups extensively prior to and during implementation, they assumed a passive role in the implementation, and we discovered that not all physicians were receptive to being informed of the patient’s NEWS. Some physicians reported that NEWS was a tool for nursing, and their expectation was that nurses would use NEWS to determine when to call regarding patient status. Furthermore, knowing the score would not necessarily affect their own treatment decisions.
Because NEWS has had a positive impact on patient care, we intend to continue using this practice. To ensure sustainability, we have integrated the NEWS education into our existing nursing orientation for new nurse-hires so that no new funds are required.
We continue to gather data related to our outcome measures and we have shared our implementation plan, educational resources, and experiences with leaders of several other hospitals of various sizes that have been experiencing similar challenges. In the future, we may explore how to implement NEWS in the emergency department and in maternal and child settings.
The authors wish to acknowledge the contributions of the following groups in helping to make NEWS a success: our physician champions, Dr. Haffner and Dr. Narayan; previous colleagues and students in our education department, including Catherine Walsh, Crystal Turner, and Leah McKay; and Huron Perth Healthcare Alliance’s information technology, decision support, and quality improvement departments.