Failure to recognize and respond to early signs of deterioration in hospitalized patients can have significant implications associated with delays in treatment. This lack of recognition was the impetus for rapid response teams in the United States and the recommendation by the Institute of Healthcare Improvement for use of early warning scores. This project was designed to evaluate the pilot implementation of an early warning score on 2 units in a community hospital in the Northeast. The practice-focused question was used to explore how patient outcomes changed following implementation of an early warning score (EWS) compared to patient outcomes associated with a rapid response team alone. The translating evidence into practice model informed this project. Supporting evidence from existing hospital data was collected for rapid response, code blue, and mortality. Analysis using the chi-square test of homogeneity compared post-implementation with baseline data. The findings indicated the differences between the proportions were not statistically significant, indicating the metrics did not change appreciably following the implementation of the early warning score. While the evaluation analytics of this pilot did not demonstrate significant change in the outcome measures post-implementation, the results may be useful for the facility when performing a future evaluation of the EWS. It is possible that the results of the 2 units were not representative of the facility, and it is therefore recommended to repeat the evaluation using data from the entire facility for a longer period. Increasing the capacity for early recognition in decline has implications for social change through improvement in safety and quality of health care for all hospitalized patients.

Bakgrund: Att tidigt upptäcka symtom på allvarlig klinisk försämring hos en patient är av stor vikt för att minska lidande och förhindra allvarliga komplikationer. För detta har flera skattningsinstrument utvecklats, däribland olika early warning score-system. Dessa har implementerats på flera håll i världen men det finns indikationer på att det brister i följsamheten till dessa. Syfte: Studiens syfte var att undersöka följsamheten till Early Warning Scores samt de faktorer som påverkar följsamheten. Metod: Studien genomfördes som en litteraturöversikt där 14 vetenskapliga artiklar inkluderades. Studierna hade kvantitativa, kvalitativa och blandade ansatser. Artiklarna söktes i databaserna PubMed, CINAHL och Web of Science. En innehållsanalys av studiernas resultat genomfördes och resultatet sammanställdes i ett antal kategorier. Resultat: Följsamheten visade sig vara högre till observationer av patientens vitalparametrar än till de åtgärdsriktlinjer som finns. Faktorer som påverkar följsamheten var sjuksköterskans kliniska erfarenhet, samarbete mellan professioner, bemanning, felkalkylering, dokumentation och rapportering. Konklusion: Följsamhet till EWS brister på många sätt och flera faktorer påverkar följsamheten. Faktorerna som påverkade följsamheten är sjuksköterskans kliniska erfarenhet, samarbete mellan professioner, felkalkylering, bemanning, dokumentation och rapportering. / Background: Early recognition of serious clinical deterioration is of great importance for minimizing suffering and serious adverse events. For early recognition, several physiological track and trigger systems have been developed, among them the early warning scores. These have been implemented in many places across the world but there is uncertainty about adherence to these systems. Aim: The aim of this study was to investigate adherence to Early warning score-systems and to evaluate what factors affect this adherence. Method: The study was conducted as a literature review including 14 articles with quantitative, qualitative and mixed-methods approaches. Searches were made in the PubMed, CINAHL and Web of Science databases. Content-analysis was used to identify themes. Results: Adherence seems higher to observations than to clinical responses. The main factors affecting adherence are the clinical experience of nurses, collaboration between professions, staffing, miscalculation, documentation and reporting. Conclusion: Adherence to EWS is lacking in many ways and several causes for this have been accounted for. Factors affecting adherence was the clinical experience of nurses, cooperation between professions, staffing, miscalculation, documentation and reporting.

Yes / The National Early Warning Score (NEWS) is being replaced with NEWS2 which adds 3 points for new confusion or delirium. We estimated the impact of adding delirium on the number of medium/high level alerts that are triggers to escalate care. Methods Analysis of emergency medical admissions in two acute hospitals (York Hospital (YH) and Northern Lincolnshire and Goole NHS Foundation Trust hospitals (NH)) in England. Twenty per cent were randomly assigned to have delirium. Results The number of emergency admissions (YH: 35584; NH: 35795), mortality (YH: 5.7%; NH: 5.5%), index NEWS (YH: 2.5; NH: 2.1) and numbers of NEWS recorded (YH: 879193; NH: 884072) were similar in each hospital. The mean number of patients with medium level alerts per day increased from 55.3 (NEWS) to 69.5 (NEWS2), a 25.7% increase in YH and 64.1 (NEWS) to 77.4 (NEWS2), a 20.7% increase in NH. The mean number of patients with high level alerts per day increased from 27.3 (NEWS) to 34.4 (NEWS2), a 26.0% increase in YH and 29.9 (NEWS) to 37.7 (NEWS2), a 26.1% increase in NH. Conclusions The addition of delirium in NEWS2 will have a substantial increase in medium and high level alerts in hospitalised emergency medical patients. Rigorous evaluation of NEWS2 is required before widespread implementation because the extent to which staff can cope with this increase without adverse consequences remains unknown.

Abstract The aim of the studie was to investigate if the Pediatric Early Warning Score system, PEWS, is an useful instrument on a children's inpatient ward, regarding the detecting of deterioration in children's vital signs. For this, a quantitative descriptive design with qualitative elements was used. Method: Study specific questionnaires were distributed to 86 persons (helpnurses, nurses and doctors). Of these, 36 answered and sent back the surveys. Results: Of 36 responses 25 felt experienced a faster detection of deterioration of vital signs in the child. Many felt that they had faster response from the physician on call by providing an assessment figure of the child's condition. Conclusion: Most of the persons experienced that the use of the assessment intrument PEWS detected a deterioration of the child´s vital signs earlier than before using the instrument. Staff experienced greater security in their work when they had a tool to help and they also experienced an earlier response from physicians. / SAMMANFATTNING   Syftet med studien var att undersöka om bedömningsinstrumentet Pediatric Early Warning Score, PEWS, är till användning och vägledning på barnavdelning med avseende att upptäcka försämring av barns vitalparametrar. För detta användes en beskrivande kvantitativ design med kvalitativa inslag. Metod: Ett studiespecifikt enkätformulär gick ut till 86 personer (undersköterskor, sjuksköterskor och läkare på två pediatriska vårdavdelningar). Av dessa besvarades 36 enkäter. Resultat: Av 36 svarande ansåg 25 att man snabbare upptäckte försämring av vitalparametrarna hos barnet. Många ansåg att de fick snabbare gensvar från jourläkare genom att uppge en bedömningssiffra över barnets hälsotillstånd. Slutsats: Med hjälp av bedömningsinstrumentet PEWS upplevde personalen att en upptäckt av försämring av barnets vitalparametrar gjordes tidigare, samt att gensvar från jourläkare erhölls snabbare. Personalen upplevde en ökad trygghet i sitt arbete då man hade ett arbetsredskap till hjälp.

Bakgrund: Inom akutsjukvård är bedömning av patientens vitalparametrar, det vill säga andningsfrekvens, saturation, puls, blodtryck, kroppstemperatur och medvetandegrad, sjuksköterskans ansvar och därmed en viktig arbetsuppgift. Tidig identifiering av försämring i patientens tillstånd, har i tidigare studier visat sig bidra till både minskad morbiditet och mortalitet. Därmed är sjuksköterskors evidensbaserade och säkra bedömningar av största vikt för patientens säkerhet och välmående. Vilket i sin tur bidrar till upprätthållen patientsäkerhet. Syfte: Syftet med studien var att utforska och beskriva sjuksköterskors följsamhet till Early Warning Score (EWS) och de faktorer som påverkar följsamheten inom akutsjukvård. Metod: Studien genomfördes som en integrativ litteraturstudie. Resultatet baseras på 14 vetenskapliga artiklar som analyserats i enlighet med Whittemore och Knafls arbetsprocess. Resultat: Analysen av artiklarna resulterade i tre teman och åtta subteman om följsamheten till Early Warning Score och de faktorer som påverkade följsamheten. Sjuksköterskors följsamhet till Early Warning Score visade sig påverkas av användbarhet, teamarbete och patienten bakom instrumentet. Inom dessa teman presenterades; erfarenhet, medvetenhet, prioritering, kommunikation, bristande läkarrespons, individanpassade parametrar och EWS i förhållande till kliniskt omdöme. Slutsats: Studien visade att det finns flera olika faktorer som påverkade följsamheten till Early Warning Score. Sjuksköterskor använder inte alltid instrumentet trots att det visade sig vara en viktig del i identifiering av försämrade patienter och likaså för patientsäkerheten. Studien gav inga säkra förklaringar till detta men belyste flera faktorer som påverkade följsamheten, vilket innebär att fenomenet är i behov av att ytterligare studeras. / Bakgrund: I akutsjukvården är bedömning av patientens vitala parametrar, såsom andningsfrekvens, mättnad, hjärtfrekvens, blodtryck, kroppstemperatur och medvetandenivå, sjuksköterskans ansvar och därmed en viktig uppgift. Tidig identifiering av försämring av patientens tillstånd har i tidigare studier visat sig bidra till både minskad sjuklighet och mortalitet. Sjuksköterskornas evidensbaserade och tillförlitliga bedömningar är därför av yttersta vikt för patientens säkerhet och välbefinnande. Vilket i sin tur bidrar till en bibehållen patientsäkerhet. Sikta: Denna studie syftar till att utforska och beskriva sjuksköterskors efterlevnad av Early Warning Score (EWS) och de faktorer som påverkar efterlevnaden i akutvården. Metod: Studien genomfördes som en integrativ litteraturstudie. Resultaten baseras på 14 vetenskapliga artiklar analyserade i enlighet med Whittemores och Knafls arbetsprocess. Resultat: Analysen av artiklarna resulterade i tre teman och åtta delteman när det gäller efterlevnaden av poängen för tidig varning och faktorer som påverkade efterlevnaden. Sjuksköterskors bedömning av vitala parametrar visade sig påverkas av eller påverka EWS användbarhet, lagarbete och patienten bakom instrumentet. Bland dessa teman var; erfarenhet, medvetenhet, prioritering, kommunikation, brist på läkarrespons, individualiserade parametrar och EWS i förhållande till klinisk åsikt. Slutsats: Studien visade att det finns flera olika faktorer som påverkat efterlevnaden av Early Warning Score. Sjuksköterskorna använder inte alltid instrumentet, även om det visade sig vara en viktig del i att identifiera patienter med nedsatt sättning och även för patientsäkerheten. Studien gav inga definitiva förklaringar till detta, men lyfte fram flera faktorer som påverkat efterlevnaden, vilket innebär att fenomenet är i behov av ytterligare studier.

Yes / In English hospitals, the patient’s vital signs are monitored and summarised into a National Early Warning Score (NEWS). NEWS is more accurate than the quick sepsis related organ failure assessment (qSOFA) score at identifying patients with sepsis. We investigate the extent to which the accuracy of the NEWS is enhanced by developing computer-aided NEWS (cNEWS) models. We compared three cNEWS models (M0=NEWS alone; M1=M0 + age + sex; M2=M1 + subcomponents of NEWS + diastolic blood pressure) to predict the risk of sepsis. Methods: All adult emergency medical admissions discharged over 24-months from two acute hospitals (YH–York Hospital for model development; NH–Northern Lincolnshire and Goole Hospital for external model validation). We used a validated Canadian method for defining sepsis from administrative hospital data. Findings: The prevalence of sepsis was lower in YH (4.5%=1596/35807) than NH (8.5%=2983/35161). The c-statistic increased across models (YH: M0: 0.705, M1:0.763, M2:0.777; NH:M0: 0.708, M1:0.777, M2:0.791). At NEWS 5+, sensitivity increased (YH: 47.24% vs 50.56% vs 52.69%; NH: 37.91% vs 43.35% vs 48.07%)., the positive likelihood ratio increased (YH: 2.77 vs 2.99 vs 3.06; NH: 3.18 vs 3.32 vs 3.45) and the positive predictive value increased (YH: 11.44% vs 12.24% vs 12.49%; NH: 22.75% vs 23.55% vs 24.21%). Interpretation: From the three cNEWS models, Model M2 is the most accurate. Since it places no additional data collection burden on clinicians and can be automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure. / The Health Foundation, National Institute for Health Research (NIHR) Yorkshire and Humberside Patient Safety Translational Research Centre / Research Development Fund Publication Prize Award winner, April 2019.

Philosophiae Doctor - PhD / Critical Care Outreach Services (CCOSs) recognize early sign of deterioration in medical units, regarding the condition of the patient, by using elements of vital sign tracking namely modified early warning score (MEWS). Nurses as leaders should be proactive by using influence to obtain a desired outcome. It is unclear how nurses experience self-leadership in this outreach service in a private hospital in Pretoria. The purpose of this research was to understand nurses’ experience of their self-leadership in the current CCOS at a private hospital in Pretoria, in order to develop self-leadership strategies that could contributes to the implementation of a CCOS (for the broader population of nurses) in a private hospital group in Gauteng. In this research the steps as outlined in the self-leadership strategic framework of Neck and Milliman (1994) were adapted for this research. The theoretical assumptions furthermore informed the methodological steps followed in the research process. The theoretical assumptions of the Practice Orientated Theory of Dickoff, James and Wiedenbach (1968) were adapted and the survey lists of this theory served as a reasoning map in this research. The central statement of this research was that, nurses need to lead themselves in implementing a CCOS in general wards in a private hospital group in Gauteng.

Pregnancy-related complications affect approximately 15% of pregnancies and, if severe, can have long-term consequences. Timely recognition of physiological deterioration is known to reduce the prevalence and severity of complications. However pregnancy-associated changes in vital signs (blood pressure, heart rate, temperature, oxygen saturation, and respiratory rate) complicate the detection of abnormal physiology, and these changes are not well documented. This thesis describes the development of algorithms to ensure the collection of good-quality vital-sign data during the antenatal and postnatal stages of pregnancy, and the design of an evidence-based obstetric early warning score. Vital-sign information from 1,000 pregnant women during pregnancy, labour, and after delivery was collected during the 4P study using pulse oximetry, oscillometry for blood pressure measurement and a tympanic thermometer. Dynamic time warping was used to assess beat-by-beat quality in the photoplethysmograph (PPG) waveform obtained from the pulse oximeter. The resulting signal quality index enabled the exclusion of poor-quality sections and their associated measurements of heart rate and peripheral oxygen saturation. A robust measurement of respiratory rate was obtained by combining information from the PPG waveform, and accelerometer and gyroscope waveforms from a smartphone. After processing, frequency-based techniques, such as Fourier analysis and auto-regressive modelling, and time-domain peak detection were fused to estimate respiratory rate. When compared with the reference respiratory rate obtained from midwife measurement, the lowest mean absolute error of 1.16 breaths per minute was obtained from respiratory rate estimates from the y-axis of the gyroscope. Antenatal and postnatal reference ranges for each vital sign were developed with a standard polynomial multilevel (hierarchical) model using 10,000 vital sign measurements from 620 healthy women in the 4P study. Vital-sign trajectories confirmed known trends of blood pressure and heart rate changes during pregnancy, and provided new information about other vital-sign trends. Additional covariates were included to investigate the effect of parity and body mass index (BMI) on vital-sign trends. The outer centiles of the vital sign reference ranges were used to design an obstetric early warning score (C-ObsEWS) that took into account gestational age or time after delivery. The investigations in this thesis contribute additional knowledge of pregnancy-associated vital-sign changes, and lead to an initial proposal for an evidence-based obstetric early warning score specific to the stage of pregnancy.

Severe Acute Pancreatitis (SAP) is the rapid onset of inflammation within the pancreatic organ. Unlike the milder form of this illness, SAP is associated with a high mortality and morbidity. No significant reduction in the outcomes of this disease has been made since the implementation of organ supportive management over two decades ago. This is due to difficulties in distinguishing between the milder form of the disease in the early period of the onset of symptoms when clinical intervention is most likely to prevent complications and death. Clinical equipoise exists in the management of one of these complications, namely Abdominal Compartment Syndrome (ACS) as the conventional management of surgery runs contrary to published evidence showing early abdominal surgery deteriorates clinical outcomes. Aims: Validation of the potential use of the Early Warning Score (EWS) as a predictor of SAP. Evaluation of the evidence for recombinant human protein C (Xigris™) in the early treatment of SAP. Determination of the safety profile of Xigris™ when given early in SAP. To determine if surgical management of ACS in SAP is of significant benefit compared to conventional management alone. Methods: Four studies were performed: A prospective observational study assessing the median EWS of patients admitted with acute pancreatitis; a systematic review of published evidence reporting the use of Xigris™ in SAP; a prospective cohort study using a 24 hour infusion of Xigris™ early in patients diagnosed with SAP and a pilot randomized controlled trial of targeted decompression in patients with ACS complicating SAP. Results: The highest EWS values for 130 patients with acute pancreatitis within the first 3 days of admission were not shown to have significant sensitivity and specificity in predicting an unfavourable outcome. A review of the published literature between from January 1985 to January 2011 supported the further investigation of Xigris™ as a treatment for SAP. No significant adverse events or differences in outcomes were evident in 19 patients who received a 24-hour infusion of Xigris™ early in SAP compared to matched historical controls. 22 patients were screened for the development of ACS. No patient developed ACS and consequently no randomization to either treatment arm was possible. Conclusion: With the recent advent of an updated classification system for the severity of acute pancreatitis, further prospective evaluation of the use of EWS in clinical practice is warranted. The results of the Phase 1 clinical trial of Xigris™ didnot reveal significant safety issues that might preclude the further investigation of Xigris™ as a specific therapy early in the onset of SAP. The absence of ACS inpatients with SAP lends support to a theory that ACS may be an epiphenomenon in the course of SAP.

National Early Warning Score (NEWS) är ett bedömningsinstrument som används inom vården för att upptäcka och varna när en patient blir kraftigt försämrad. Syftet med litteraturöversikten var att sammanställa kunskap om sjuksköterskors erfarenheter av att använda bedömningsinstrumentet NEWS. En integrerad litteraturöversikt genomfördes där 12 vetenskapliga artiklar togs ut efter en systematisk litteratursökning i PubMed och CINAHL. Av dessa var det sex med kvalitativ metod, fyra kvantitativ metod och två mixad metod, som granskades och analyserades. Analysen resulterade i fyra kategorier. Dessa var ”NEWS användes av sjuksköterskan för att observera, bedöma och planera vård”, ”NEWS kunde både vara ett stöd och skapa merarbete”, ”NEWS förbättrade kommunikationen med andra kollegor” och ” NEWS kunde främja sjuksköterskan i sin profession”. Slutsatserna som drogs var att sjuksköterskorna ansåg NEWS som användbart vid att uppfatta en patients försämring, instrumentet användes även som ett sätt att stödja en egen klinisk bedömning. Sjuksköterskorna ansåg att NEWS behövde anpassas för olika sjukdomstillstånd eftersom falska höga värden ledde till onödiga kontroller och larmutmattning. Kommunikationen mellan kollegor blev bättre och sjuksköterskorna fick stöd och bättre respons när vitalparametrar kommunicerades. Sjuksköterskorna ansåg att NEWS ökade fokuset på vitalparametrar vilket ledde till ökad kunskap om avvikelser samt stimulerade till egna bedömningar. Författarna anser att det finns behov av att arbeta särskilt med kommunikationsmetoder som införlivas med NEWS, där alla parter i vårdkedjan förstår instrumentets relevans. Detta kan förslagsvis göras i samband vid implementering av NEWS med tydliga riktlinjer kring bedömnings-instrumentet, hur det ska användas och varför.