Abstract
BackgroundNurses’ recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries.MethodsWe tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed.ResultsWe recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06–1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and “looks unwell”. SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38–6.86)).ConclusionsThe revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses’ ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses’ reporting behaviour.Trial registrationPan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.
Highlights
Nurses are responsible for monitoring patients for signs of clinical deterioration
Patient records for retrospective review We aimed to evaluate effectiveness of the revised modified early warning scores (MEWS) chart by reviewing records of consented patients aged ≥ 18 years, admitted in August 2014 to the study wards, with the following exclusions: noted as “Not for Resuscitation”, transferred out of the ward to another department within 12 h following admission, or pregnancy
Intervention (2): 31-day use of MEWS/SBAR on intervention wards In both trial arms, we presented the study to senior nurses, doctors and hospital managers
Summary
Nurses are responsible for monitoring patients for signs of clinical deterioration. These might be most effectively detected using bedside early warning scoring (EWS) systems and a standardised reporting system such as the situation-background-assessment-recommendation (SBAR) guide. In 2010 we conducted our first pragmatic, cluster randomised controlled trial (RCT) of the original, consensus-derived, Cape Town (CT) modified EWS (MEWS) observations chart in three intervention and three control adult surgical wards in a single research site [1,2,3]. Paper charting of observations takes longer than electronic systems, increasing nursing workload [8] and risk of human error [9], inaccuracy of calculations [10]. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries
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