Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study

Abstract

BackgroundUnrecognised changes in a hospitalised patient’s clinical course may lead to a preventable adverse event. Early warning systems (EWS) use patient data, such as vital signs, nursing assessments and laboratory values, to aid in the detection of early clinical deterioration. In 2018, an EWS programme was deployed at an academic hospital that consisted of a commercially available EWS algorithm and a centralised virtual nurse team to monitor alerts. Our objective was to understand the nursing perspective on the use of an EWS programme with centralised monitoring.MethodsWe conducted and audio-recorded semistructured focus groups during nurse staff meetings on six inpatient units, stratified by alert frequency (high: >100 alerts/month; medium: 50–100 alerts/month; low: <50 alerts/month). Discussion topics included EWS programme experiences, perception of EWS programme utility and EWS programme implementation. Investigators analysed the focus group transcripts using a grounded theory approach.ResultsWe conducted 28 focus groups with 227 bedside nurses across all shifts. We identified six principal themes: (1) Alert timeliness, nurses reported being aware of the patient’s deterioration before the EWS alert, (2) Lack of accuracy, nurses perceived most alerts as false positives, (3) Workflow interruptions caused by EWS alerts, (4) Questions of actionability of alerts, nurses were often uncertain about next steps, (5) Concerns around an underappreciation of core nursing skills via reliance on the EWS programme and (6) The opportunity cost of deploying the EWS programme.ConclusionThis qualitative study of nurses demonstrates the importance of earning user trust, ensuring timeliness and outlining actionable next steps when implementing an EWS. Careful attention to user workflow is required to maximise EWS impact on improving hospital quality and patient safety.

Nurses’ and Physicians’ Ideas on Initiatives for Effective Use of the Early Warning Score: A Participatory Study

“…Despite the ability of EWS to help identify deteriorating patients, implementation of the EWS into clinical practice has been found to be inadequate in many contexts (Braun et al, 2022; Connolly et al, 2017; Credland et al, 2021). Variations in adherence to EWS protocol has been related to a variety of factors including lack of understanding about the purpose of EWS, underestimation of abnormal vital signs, nursing workloads, and limited medical and nursing support (Braun et al, 2022; Connolly et al, 2017; Foley & Dowling, 2019; Mølgaard et al, 2022; O’Neill et al, 2021).…”

“…Despite the ability of EWS to help identify deteriorating patients, implementation of the EWS into clinical practice has been found to be inadequate in many contexts (Braun et al, 2022; Connolly et al, 2017; Credland et al, 2021). Variations in adherence to EWS protocol has been related to a variety of factors including lack of understanding about the purpose of EWS, underestimation of abnormal vital signs, nursing workloads, and limited medical and nursing support (Braun et al, 2022; Connolly et al, 2017; Foley & Dowling, 2019; Mølgaard et al, 2022; O’Neill et al, 2021). Adherence with the EWS escalation protocol is critical in supporting appropriate and effective recognition of and response to deteriorating patients and their survival (Braun et al, 2022; Credland et al, 2021; Kolic et al, 2015; Olsen et al, 2019).…”

“…However, there is evidence that nurses experience the protocol to be too sensitive toward changes in vital parameters and non-specific to patient deterioration, which is a barrier for nurses’ adherence to the escalation protocol (Olsen et al, 2019). This experience often results in alert fatigue among nurses and doubt about the EWS’ usefulness, which may reduce the use of the EWS as an integral part of nurses’ decision-making (Braun et al, 2022; Connolly et al, 2017; Douglas et al, 2016; Olsen et al, 2019).…”

We don’t talk about communication: why technology alone cannot save clinically deteriorating patients

“…4 In contrast, Crotty and colleagues reported on implementation of an EWS algorithm and associated virtual nurse monitoring team, and sought to understand nursing perspectives on it using qualitative methods. 5 The research question for the scoping review asked whether prediction models providing real-time clinical deterioration alerts lead to improved patient outcomes, compared with standard care. The authors followed a rigorous process for selecting studies, extracting data and synthesising the findings of the 18 included studies.…”

“…First, Blythe and colleagues conducted a scoping review of real-time automated clinical deterioration alerts, which are part of an EWS, and importantly also sought evidence of their impact on patient outcomes 4. In contrast, Crotty and colleagues reported on implementation of an EWS algorithm and associated virtual nurse monitoring team, and sought to understand nursing perspectives on it using qualitative methods 5…”