BackgroundThe early warning score (EWS) was developed to identify deteriorating patients early. It is a track-and-trigger system based on vital signs designed to direct appropriate clinical responses based on the seriousness and nature of the underlying condition. Despite its wide dissemination, serious adverse events still occur, often due to failure among staff on general wards to follow the EWS protocol. The purpose of the study was to determine barriers and facilitating factors related to three aspects of the EWS protocol: 1) adherence to monitoring frequency, 2) call for junior doctors to patients with an elevated EWS, and 3) call for the medical emergency team.MethodsFocus groups were conducted with nurses from medical and surgical acute care wards, and content analysis was used to identify barriers and facilitating factors in relation to the research questions.ResultsAdherence to monitoring frequency would frequently be set aside during busy periods for other tasks. Collaboration and communication with doctors about medical patients with elevated EWS was considered to be unrealistic due to the high number of patients with these scores. Collaboration with the medical emergency team was problematic, since many nurses found the team to have negative attitudes.ConclusionEWS reduces complex clinical conditions to a single number, with the inherent risk to overlook clinical cues and subtle changes in patients’ condition. The study showed that identifying and treating deteriorating patients is a collaborative task that requires diverse technical and non-technical skills for staff to perform optimally.

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PurposeAbstractTo determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients.MethodsProspective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy.Results2493 patients, with median age 78–80 years (DK–Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7–8.6 vs. 5.8 95% CI 5.6–5.9) and Danish mean 7.1 (95% CI 6.6–7.5 vs. 5.5 95% CI 5.4–5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL’s accuracy was only modest for in-hospital death prediction in either setting.ConclusionsThe modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician’s confidence in initiating earlier end-of-life discussions.Electronic supplementary materialThe online version of this article (10.1007/s41999-018-0123-6) contains supplementary material, which is available to authorized users.

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