Literature Review: Evaluating the effectiveness of the implementation of early warning score systems
The Royal College of Physicians have adopted the electronic Early Warning Score System (EWS) in order to standardise assessments of patients during triage care; this system is intended to allow physicians to quickly assess the degree of illness of their patient (Royal College of Physicians (RCP), 2012, p.3). If implemented correctly, the RCP explains that the EWS would increase the effectiveness of triage and should allow for patients to be treated based on their level of need. However, implementing such a systematic change would prove to be a challenge. This literature review will explore the rationale for implementing an EWS, as well as evaluate the effectiveness of the model and potential limitations with implementing its system throughout British institutions. As the electronic EWS system is still in its infancy, the research used for this review will be from 2011 onwards; this should assist in focusing the programme’s progress to its practical elements rather than purely theoretical frameworks. Furthermore, only research from the United Kingdom was included within this study in order to target support as necessary.
Rationale for Implementing an EWS
Many researchers have explored the importance of implementing an early warning scoring system in order to facilitate stakeholders in identifying success measures for the implementation process (Marinkovicet al., 2013, p.85). One such advantage of implementing an EWS within English hospitals includes the improved safety for patients through the accurate and standardised recording of their vital signs. Also, in cases where the patient undergoes triage with one department before being transferred to another, having a standardised practice will reduce the likelihood of errors within handover (Ilanet al., 2012, p.1). This could also save time in the handover process, which improves resources and could have a positive impact on patient outcome (Marinkovicet al., 2013 p.85). Furthermore, having all triage doctors use the same metrics for assessing their patients’ well being would mean the doctors were more familiar with the assessments, therefore they could have an improved and standardised judgement (Watts et al., 2010, p.206).
The National Institute for Clinical Excellence (NICE) suggests that an early warning score system should not only provide standardisation in terms of triage care, but should also create a prioritisation system that is nationally recognised in order to treat patients fairly across the country. However, NICE also suggests that this system ought to be supplemented with an institution-specific strategy that takes into consideration the frequency of patient monitoring, as well as a clinical supervision assessments that can alter the score if necessary (Watts et al., 2010, p.207). The revised measures adopted by the RCP in 2012 took into the consideration the suggestions by NICE as a mechanism for correctly calculating the EWS score based on the physician’s assessment of the most up-to-date patient information (RCP, 2012, p.4).
Furthermore, in order to assist the potential for errors in the handover, an electronic EWS system has been instated within most NHS hospitals (Thomas et al., 2013, p.797). An electronic EWS system may be designed to automatically tabulate scores on vital physiological assessments, calculate the EWS, and produce a suitable action plan for the patient based on their EWS and demographic details (Thomas et al., 2013, p.801). With the introduction of such a system, it had been anticipated that there would be a reduction in oversight errors by junior doctors or employees, which would lead to an increase in practice standards. However, while the electronic EWS system appears to be a better and quicker solution, it is not necessarily more effective than a face-to-face triage appointment. The following section will evaluate the effectiveness of this system.
Evaluating the Effectiveness of Electronic EWS System for Hospital Management
Research has indicated that electronic EWS systems produce unpredictable and inconsistent results; this could be due to the nuance required to treat a patient that a simple numerical assessment may not handle (Thomas et al., 2013, p.799). The majority of hospital deaths could be predicted and prevented through clinical monitoring by doctors and nursing staff. Therefore, while the early warning score system was developed to establish the patient’s initial treatment needs, relying too heavily on such a score without updating the patient’s progress ignores the patient’s potential deterioration (Smith et al., 2014, p.1454; MDCalc, 2016, np). Within the UK, hospitals are meant to use the adapted version of EWS which regularly re-evaluates the patient’s status in order to monitor deterioration rate; however, evidence of such practice incorporations within the hospital systems is limited (Smith et al., 2014, p.1456). Until this is incorporated better within hospitals, it can be difficult to evaluate the effectiveness of such a method.
One of the reasons for hospitals not incorporating the electronic systems could be the budgetary concerns; such an investment would require heavy funding, and investors may be unwilling to spend such an amount without concrete, proven effective, results. The costs for such a programme include not only the technology required to operate the electronic EWS system, but also training costs for all staff in how to use this system properly, as well as standards verification for judgements by staff on the EWS assessments (Thomas et al., 2013, p.802). It is crucial, however, that the budgets take into consideration both the computing software to run EWS, but should ensure continued professional development is incorporated into the annual budget for the programme. Furthermore, an effective electronic EWS system would require discipline from the ward’s staff to use the new system regularly within the trial period, as well as regular observations and joint assessments of patients for standardisation purposes (Thomas et al., 2013, p.804).
Researchers have not yet come to a conclusion as to the cost effectiveness of the electronic early warning score system, as no formal assessments have been carried out on this metric; it is assumed that this can be due to the limited operational budgets of English hospitals (Seigeret al., 2013, p.334). Such limited budgets and high operating costs for introducing the program may force managers and supervisors leading on the implementation project to heavily monitor such a new investment, which takes time away from their other professional endeavors. In order to uncover the actual investment cost, it is crucial to take into consideration the costs of the programme as well as the impact on the ward staff’s time and attention to their other professional duties (Samarakoon, 2015, p.1).
NICE recommends that all hospital staff who support patient care have compulsory training in how to monitor, measure, interpret, and evaluate severely ill patients. While the initial training would be extensive and tailored to the specific roles of the hospital staff, there would need to be a system of continued professional development and ongoing training to implement the programmes accurately, particularly as electronic systems may require system updates more regularly than non-electronic systems (Godden, 2013, p.299). Regular education on the topic is a key aspect to successfully implementing the programme, as well as ensuring continued competency of the hospital staff. Colleges, hospitals, and healthcare institutes, such as the Royal College of Physicians and the Royal College of Nursing, have already implemented similar learning programmes for training and supporting staff in the implementation of the new EWS system (Godden, 2013, p.298). Through centralised training programmes, there is a greater chance of a standardised approach to the assessments and judgements.
Due to the budgetary and training concerns highlighted above, hospitals and NHS trusts have indicated reluctance to adopt the electronic EWS system. However, the question remains as to the benefit of such a system for patients; the following section will explore the impact of electronic EWS systems for patients’ care and wellbeing.
Evaluating the Effectiveness of Electronic EWS System for Patient Care
While the Royal College of Physicians and NICE supports the use of an electronic early warning scoring system in terms of improving the effectiveness for the hospital management systems, it is crucial to explore the effectiveness of the EWS system for patient care and wellbeing as well. Nwulu& Coleman published a detailed exploration and analysis of a range of literature on this topic; they concluded that there is a paucity of evidence on the quality of such a programme for patients’ care (Nwulu& Coleman, 2016, p.2). The majority of the studies they had found evaluated the care collected their data through anecdotal evidence and lacked a thematic analysis of the qualitative data (Nwulu& Coleman, 2016, p.6). The low quality of such research indicates the difficulty in monitoring the effectiveness of such systems; this could suggest that further research, particularly where extraneous factors are more easily controlled, should be employed.
However, the qualitative and raw evidence from the research explored in Nwulu& Coleman indicates that having a nationwide, standardised system for early intervention would produce better results for the patients. This is due to the weighted aggregated scoring component of the systems, which allow hospitals and service centres to place emphasis on particular care needs of patients; therefore, hospitals could prioritise service users based on level of need rather than other parameters, such as time waiting for services (Godden, 2013, p.298). If this system is combined with quick responses from hospital employees completing the assessments, an electronic EWS system would have the capacity to reduce complication from emergency concerns, such as cardiac arrests and rapid admissions to the Intensive Care Units (ICU) (Kyriacos et al., 2015).
For the benefits of an electronic EWS system to be realised, the data must be accurately recorded with assessments and judgements on the patient’s well being standardised. Inaccurate information could lead to delays in identifying patients at risk or could lead to an unnecessary allocation of hospital resources (Seigeret al., 2013, p.336). Reductions in errors could be tackled through the incorporation of an electronic system that could reduce human error while tracking the process of patients; however, there remains a risk that ward staff will not be trained sufficiently to use this system (Seigeret al., 2013, p.334).
The early warning scoring system schemed have not yet been proven to have a significant effect on the length of the patient’s stay or their mortality; as these are the traditional metrics for success of hospital interventions, it can be difficult to determine EWS systems successful (Petersen et al., 2016, p.91). Earlier studies discussed within this literature review, as well as those identified in Nwulu& Coleman (2016), have also indicated that electronic EWS systems might have had less of an effective impact than anticipated as the assigned scores could have been wrongly allocated, or judgements not standardised. Without standardisation, patients may be inaccurately assessed as having too high or too low risk for further complications, and the patient’s care may therefore be inaccurate as a result (Petersen et al., 2016, p.93).
Although NICE has presented their recommendations to continue with an electronic EWS for improved patient care and effectiveness of hospital triage, there is still a lack of research evaluating its current practices within UK hospitals. The remaining gap in the literature poses an area of concern, and should be explored more thoroughly before a final plan for implementation can be arranged.
While government bodies and regulatory agencies have confidence in the potential for electronic early warning scoring systems, there is a lack of tangible evidence from peer-reviewed journals on the successful implementation of these processes. More clinical trials must be carried out and evaluated in the near future in order to evaluate its overall effectiveness on varying populations, including hospitals with service users from dispersant socioeconomic and geographic backgrounds. There should also be further standardisation within the practices for hospitals implementing such a system so that its effectiveness can be accurately evaluated. Therefore, this researcher seeks to explore the effectiveness of electronic EWS systems in order to determine if it could improve patient care, reduce hospitalisation, and improve the general skills and abilities of nurses and hospital ward staff.
References
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Kyriacos, U., Jelsma, J., James, M. and Jordan, S. (2015). Early warning scoring systems versus standard observations charts for wards in South Africa: a cluster randomized controlled trial. Trials, 16(1).
Marinkovic, O., Sekulic, A., Trpkovic, S., Malenkovic, V. and Pavlovic, A. (2013). The importance of early warning score (EWS) in predicting in-hospital cardiac arrest—Our experience. Resuscitation, 84, p.S85.
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