Health policies and previous research highlight the importance of early identification and treatment of clinical deterioration in older patients to prevent frailty, higher levels of care, and mortality. This study explores older home nursing care patients’ care trajectories and factors associated with clinical response (type and level of intervention) from the health care services, final level of community care and death within 3 months after an incidence of acute functional decline. This observational study with a prospective, descriptive design includes a sample of 135 older home nursing care patients with acute functional decline. Demographic, health-related, and clinical characteristics were analyzed and prediction models for care trajectories were fitted using Bayesian generalized mixed models. Age ranged from 65 to 100, with a median age of 85. Hospital admission were registered for 13.33% ( T1) and 8.77% ( T2) of the participants. Nine patients (6.7%) were transferred to a higher level of community care, and 11 patients (8.1%) died. Frequent transitions between levels of care characterized care trajectories for patients experiencing more severe functional decline. Age, living in a private home, and increased Modified Early Warning Scores (MEWS) were associated with level of clinical responses throughout the care trajectory. Living in a private home was associated with the patients’ final level of community care. Female gender, hospital admission, and increased MEWS scores were associated with death. Health care personnel must be vigilant when MEWS scores rise even slightly, as this might be an indication of acute functional decline with possible increased risk of mortality.

Aims and objectives The study describes experiences of registered nurses and general practitioners when using the Modified Early Warning Score (MEWS) to assess acute functional decline in older home nursing care patients. Background Acute functional decline is common among older home nursing care patients; typically characterised by nonspecific symptoms and a mix of manifestations. Early warning score systems for detecting clinical deterioration have been thoroughly evaluated in hospital settings, but few studies have evaluated these systems used with older people in a community care setting. Methods A descriptive exploratory research design and a qualitative approach. 36 nurses and eight general practitioners were purposively sampled. Data were collected in seven mixed focus groups and analysed using an inductive thematic content analysis in an iterative process that moved between text, codes, categories and themes. The COREQ checklist was used. Results Two main themes were developed in the analysis. The first theme derived, was that the MEWS along with medical‐technical equipment and clinical judgement, was used to support nurses’ and general practitioners’ clinical decisions in assessing older deteriorating patients. The second theme referred to nurses’ and general practitioners’ experiences with several adjustments when using the MEWS with the older patient group and in complying with its trigger recommendations. Conclusion The use of the MEWS when assessing older patients in home nursing care is potentially useful in supporting clinical reasoning. However, the tool's usefulness is limited because it is not experienced as sufficiently adapted to neither the home nursing care services nor to older patients. Implications for practice This study increases our knowledge of how the MEWS tool is used in a community care setting and highlights the importance of adjustment of assessment procedures for older persons with acute functional decline.

Background: Acute functional decline is a common clinical syndrome in geriatric health care that is typically characterised by nonspecific symptoms and presents with a mix of physical, psychological, social and functional manifestations.Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated these systems in community health care.The purpose of this study is to describe the experiences of registered nurses (RNs) and general practitioners (GPs) when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline.Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. GPs and RNs were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method.Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs emphasised that MEWS supported the clinical reasoning and decision-making process. Additionally, those applying MEWS required comprehensive reasoning skills and specific knowledge of the patients. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability.Conclusion: MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and GPs’ work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements. MEWS trigger recommendations were experienced as inappropriate in the home care context. This study identifies the need for a modified, evidence-based EWS adjusted for geriatric patients in home care.

Background : Acute functional decline is a common clinical syndrome in geriatric health care and is typically characterised by nonspecific symptoms and presentations with a mix of physical, psychological, social and functional manifestations. Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated EWS systems in community healthcare. The purpose of this study was to describe the experiences of registered nurses and general practitioners experiences when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline. Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. General practitioners (GPs), and registered nurses (RNs) were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method. Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs highlighted that MEWS supported the clinical reasoning and decision-making process. Additionally , comprehensive reasoning skills and specific knowledge of the patients were needed. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability. Conclusion : MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and the GP's work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements . MEWS trigger recommendations were experienced as inappropriate to comply within home care. This study identifies the need for a modified evidence-based EWS adjusted for geriatric patients in home care.

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