Abstract
BackgroundOn South African public hospital wards, observation charts do not incorporate early warning scoring (EWS) systems to inform nurses when to summon assistance. The aim of this trial was to test the impact of a new chart incorporating a modified EWS (MEWS) system and a linked training program on nurses’ responses to clinical deterioration (primary outcome). Secondary outcomes were: numbers of patients with vital signs recordings in the first eight postoperative hours; number of times each vital sign was recorded; and nurses’ knowledge.Methods/designA pragmatic, parallel-group, cluster randomized, controlled clinical trial of intervention versus standard care was conducted in three intervention and three control adult surgical wards in an 867-bed public hospital in Cape Town, between March and July 2010; thereafter the MEWS chart was withdrawn. A total of 50 out of 122 nurses in full-time employment participated. From 1,427 case notes, 114 were selected by randomization for assessment.The MEWS chart was implemented in intervention wards. Control wards delivered standard care, without training. Case notes were reviewed two weeks after the trial’s completion. Knowledge was assessed in both trial arms by blinded independent marking of written tests before and after training of nurses in intervention wards. Analyses were undertaken with IBM SPSS software on an intention-to-treat basis.ResultsPatients in trial arms were similar. Introduction of the MEWS was not associated with statistically significant changes in responses to clinical deterioration (50 of 57 received no assistance versus 55 of 57, odds ratio (OR): 0.26, 95% confidence interval (CI): 0.05 to 1.31), despite improvement in nurses’ knowledge in intervention wards. More patients in intervention than control wards had recordings of respiratory rate (27 of 57 versus 2 of 57, OR: 24.75, 95% CI: 5.5 to 111.3) and recordings of all seven parameters (5 of 57 versus 0 of 57 patients, risk estimate: 1.10, 95% CI: 1.01 to 1.2).ConclusionsA MEWS chart and training program enhanced recording of respiratory rate and of all parameters, and nurses’ knowledge, but not nurses’ responses to patients who triggered the MEWS reporting algorithm.Trial registrationThis trial was registered with the Pan African Clinical Trials Registry (identifier: PACTR201309000626545) on 9 September 2013.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0624-2) contains supplementary material, which is available to authorized users.
Highlights
On South African public hospital wards, observation charts do not incorporate early warning scoring (EWS) systems to inform nurses when to summon assistance
More patients in intervention than control wards had recordings of respiratory rate (27 of 57 versus 2 of 57, oxygen saturation (OR): 24.75, 95% confidence interval (CI): 5.5 to 111.3) and recordings of all seven parameters (5 of 57 versus 0 of 57 patients, risk estimate: 1.10, 95% CI: 1.01 to 1.2)
This paper describes a pragmatic, parallel-group, cluster randomized, controlled trial evaluating the impact of a modified EWS (MEWS) training program and published consensus-derived MEWS observations chart (Additional file 1: Figure S1) [12,13] on the proportion of patients with physiological variables recorded and nurses’ responses
Summary
On South African public hospital wards, observation charts do not incorporate early warning scoring (EWS) systems to inform nurses when to summon assistance. The aim of this trial was to test the impact of a new chart incorporating a modified EWS (MEWS) system and a linked training program on nurses’ responses to clinical deterioration (primary outcome). There are few examples of training programs for early recognition and management of adult patients with impending critical illness One such program, the ‘Acute Life-threatening Events - Recognition and Treatment’ (ALERT) course [6], is based on the assumption of preexisting knowledge of the biosciences, but previous research [7] suggests that this underpinning knowledge may be suboptimal. Traditional assumptions that mortality and determinants of survival fall within the domain of medical care may be inhibiting nurse-led research in this area, but there is increasing evidence that these outcomes are ‘nursing sensitive’ [8]
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