Early warning score challenges and opportunities in the care of deteriorating patients


Clinical deterioration of patients hospitalized on general wards is often preceded by worsening vital signs. If identified early and acted upon quickly, it is conjectured that further deterioration can be prevented. To this means the early warning score (EWS) was implemented in all hospitals in the Capital Region of Denmark in 2013. EWS consists of an aggregated weighted track-and-trigger system (TTS), to identify at-risk patients early, and a treatment protocol to escalate care appropriately and determine the level of competency of the provider. A similar system is endorsed by the Royal College of Physicians for use at hospitals in the UK. Despite wide dissemination of EWS and similar systems serious adverse events presaged by deteriorating vital signs continue to be a major source of morbidity. This is either due to inherent inadequacies of EWS, lack of adherence to the treatment protocol, or a combination of both.
All studies included in this thesis were conducted at Bispebjerg Hospital, an inner-city Hospital in Copenhagen, Denmark with 500 beds and a catchment area of approximately 300,000. 
The aim of the thesis was to investigate the reasons for failure of the EWS by trying to answer the following research questions:
1. How often and why does the system fail?
2. What are the barriers and facilitating factors related to the use of the EWS protocol?
3. Is there a correlation between monitoring frequency and clinical deterioration?
 To answer the first question an observational study was conducted, in which all unexpected deaths, cardiac arrests, and unintended ICU admission on general wards during a 6 months period were reviewed. A total of 144 events were recorded; in only 12 (8 %) of these the escalation protocol was adhered to strictly. Monitoring frequency was not adhered to in 81 % of cases; doctors were not notified about patients' condition in 42 % of cases, and the medical emergency team or senior doctors were not notified appropriately in 52 % of the cases. Leading to the conclusion that violations of the escalation protocol was common prior to serious adverse events on general wards.
To answer the second question semi-structured focus group interviews with nurses from the surgical and medical acute care wards were performed to investigate: 1) why monitoring frequencies are not adhered to, 2) why junior doctors are not notified about deteriorating patients, and 3) why review by the medical emergency team (MET) is often delayed or missed? The main findings from this study showed that time constraints and under staffing was mentioned as a main reason for non-adherence to monitoring frequencies. Confidence in their own abilities to take care of deteriorating patients, and the large number of patients with elevated EWS was mentioned as the main reason, for not notifying junior doctors. And fear of reprimands and lack of non-technical skills among members of the MET were mentioned among the main reasons for reluctance to call.
The third study investigated the role of monitoring frequency on clinical deterioration in a ward-level randomized study. It was hypothesized that 8 h monitoring intervals were superior to 12 h in preventing deterioration, defined as a rise in EWS to ≥ 2 after 24 h, among newly admitted patients with an initial EWS of 0 or 1. Of 3185 patients screened for eligibility, 1346 patients were included to the trial, and data from 544 patients were available for final analysis. Of these 49 % percent were allocated to the 8h group and 51% to the 12h group; of these, 23% and 20% had an elevated EWS≥2 at 24h, respectively (p=0.456), OR 1.17 (0.78-1.76). There were no significant differences in regard to the secondary outcomes: cardiac arrests, ICU admissions, review by MET, length of hospital stay, mortality, or elevated EWS at 48h.