Abstract
Background: Reducing the rates of serious adverse events associated with acute in-patient deterioration is a worldwide health priority. To date systematic reviews have failed to unequivocally demonstrate that early warning systems (EWSs) reduce the incidence of in-patient cardiac arrests, unanticipated intensive care unit admissions or mortality rates. Currently there are several hundred EWSs in use which vary in how they facilitate the recognition, activation and response to acutely deteriorating patients. With new innovations in health and computer technology, electronic EWSs are increasingly being employed to address shortfalls and challenges associated with both the detection and response arms of paper-based EWSs.
Aim: The primary aim of this integrative review was to determine if electronically captured clinical observations with/without automated alert systems improve compliance with physiological early warning system (EWS) protocols and improve patient outcomes.
Methodology/Methods: An integrative review was chosen as the methodology of choice as it allows one to combine diverse methodologies to fully understand a phenomenon. The following electronic databases were searched: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase (Ovid), Web of Science, The Cochrane Library, Joanna Briggs Institute (JBI) and Scopus. Unpublished or grey literature was also sought to avoid publication bias. Included studies were critically appraised using JBI's 2014 critical appraisal tools and data was extracted and synthesised using Braun and Clarke's (2006) six phases of thematic analysis which identified four main themes and eight subthemes which were presented in a narrative format.
Results: This review identified that most electronic EWSs improve the detection of deteriorating patients in hospital by improving the accuracy of vital signs and early warning scores. This finding was prevalent with systems that allow documentation of vital signs at the point of care and the automated transfer of vital signs to the electronic health record. The frequency of vital sign measurement and escalation of care for deteriorating patients remained variable. This review found that the technology and hardware used in electronic EWSs enhanced the accessibility and visibility of vital signs and aggregate early warning scores. This enhanced accessibility and visibility supports proactive and remote management and response to deteriorating patients. The electronic systems included in this review utilised numerous methods of escalating care for deteriorating patients such as automated alerts, onscreen prompts and visible electronic dashboards. Improvements in patient outcomes were not conclusively demonstrated by this review.
Conclusion: Electronic EWSs facilitated the detection of deteriorating patients by improving the accuracy and accessibility of patient's vital signs and early warning scores. Future research is required to determine the optimal method of escalating care in electronic EWSs. Once an alert of patient deterioration is raised, challenges remain. There remains a need to ensure an appropriate, timely and adequately resourced response to deteriorating in-patients in an attempt to demonstrate improved patient outcomes.