Case Study

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TABLE OF CONTENTS

Chapter I Problem and Its Background

Introduction 2

Theoretical Framework 4

Conceptual Framework 5

Statement of the Problem 6

Hypothesis 6

Scope and Delimitation 6

Significance of the Study 7

Definition of Terms 8

Chapter II Review of Related Literature 10

Chapter III Research Methodology

Research Design 23

Population Frame 23

Sampling Technique 23

Setting 24

Research Instrumentation 24

Data Gathering Procedure 25

Data Analysis and Treatment 27

Ethical Consideration 27

References 29

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

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Chapter I

PROBLEM AND ITS BACKGROUND

Introduction

General adult patients in hospitals can have unexpected physiological

deterioration that if left unrecognized, can lead to critical illness, intensive care

unit (ICU) admission, cardiac arrest and/or death. Early identification of the

sickest patients may allow earlier intervention, thus potentially improving their

outcome. This problem was the subject of numerous critical care studies and

since there are very limited local studies regarding the same topic, the

researchers have decided to pave the way in exploring this topic.

As there is an upsurge of critically ill patients, the interest in formulating

strategies for detecting at-risk patients also increases. Resuscitation Council

(2010) added that regular monitoring and effective treatment of seriously ill

patients appear to improve clinical outcomes, thus the basis for monitoring

patients’ vital signs. Abnormal physiology is common in adult care wards, yet the

important physiological observations of patients are considered and recorded

less frequently than is desirable.

Scoring systems have been developed in answer to an increased

importance on the evaluation and monitoring of health services. These systems

enable comparative and evaluative research of intensive care. (M. Rao, 2008)

One of the most reliable tools used in scoring is the Early Warning System

(EWS) tool, which was introduced by the American Department of Health (2000)


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as part of the recommendations in the comprehensive critical care report. The

EWS, also known as “track-and trigger systems”, is the calculation of the

combined generated score based on physiological abnormalities of heart rate,

blood pressure, respiratory rate, temperature, urine output and level of

consciousness. It is intended to support objective decision making to help staff

identify deteriorating patients.

There are more than 5 million patients who are considered critically ill in

the United States with an average mortality rate of 10-29%. These patients’

diseases range from multi-organ failure, cardio vascular failure and sepsis, which

can further lead to renal failure, acute respiratory failure and the like. (Society of

Critical Care Medicine, 2015). In the Philippines, there is one study that was

conducted in a tertiary hospital in Cebu City where they utilized the Pediatric

Early Warning Scoring (PEWS) and Banque et.al (2009) stated that there is a

significant relationship between PEWS and clinical deterioration correlated with

PICU/ICU set-up admission thus, they concluded that it is a simple and reliable

scoring system that will aid in identifying pediatric patients at risk for clinical

deterioration.

In San Juan de Dios Educational Foundation Inc. (Hospital) the Early

Warning System has not been introduced, but the parameters used by EWS can

easily be supported by the physical set of SJDEFI. Then, as part of continual

development of quality care and patient safety in our institution, the researchers

is aiming to introduce the tool to evaluate the impact of utilizing the Early

Warning System Tool in detecting physiologically deteriorating patients in a unit


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of the adult care section of San Juan de Dios Educational Foundation, Inc.

(Hospital).

Theoretical Framework

The Helping Art of Clinical Nursing was produced by Ernestine

Wiedenbach. It characterized nursing as the act of recognizing a patient's need

for help through proper recognition of symptoms and behaviour, recognizing the

cause of the distress, recognizing whether the patient has a need of assistance

from the nurse or the health care team. Being able to identify the degree of the

need for help of each patient allows nurses to provide holistic care. Prevention of

complications and promotion of comfort are the nursing goals of the theory.

(Weidenbach’s Helping Art of Clinical Nursing, 2013).

Wiedenbach elaborates that clinical judgement of the nurses based on

actual existence and based on the analysis the causes and effects can lead to

good decision-making. Sound judgement is the capacity to assess situations or

circumstances clearly and to draw sound conclusions that enhances through

time, that increases the clarity of professional purpose. In this theory, nursing

skills are done to accomplish a patient-focused purpose instead of the fulfilment

of the skill itself being the finished objective. Skills are composed of different

activities that are defined as the unity of action, accuracy and the productive use

of self.


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Conceptual Framework

The study’s main purpose is to appraise the impact of utilizing the Early

Warning System Tool in assessing physiological deterioration in a unit of the

adult care section of San Juan de Dios Educational Foundation, Inc. (Hospital).

The first receptacle encompasses the demographic data of the respondents.

The second receptacle represents the Early Warning System tool. The connector

between the first and second receptacle is the utilization of the tool, which will

yield the output of the study: the impacts of utilizing the Early Warning System

tool. The connector between the first and third receptacle signifies the

relationship between the demographic data of respondents and impact of using

the EWS tool.


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STATEMENT OF THE PROBLEM

This study aims to determine the impact of utilizing the Early Warning System

tool in a unit of the San Juan de Dios Educational Foundation, Inc.

This study specifically aims to answer the following questions:

1. What are the demographic data of the respondents in terms of:

a. age

b. gender

c. length of experience

2. What are the impacts of utilizing the Early Warning System tool?

3. Is there a significant relationship between the demographic data of the

respondents and the impact of utilizing the Early Warning System Tool?

4. Based on the findings, what recommendations can be made in the use of the

Early Warning System Tool?


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Hypothesis

H1: There is a significant relationship between the demographic data of

the respondents and the impacts of utilizing the Early Warning System tool.

Scope and Delimitation

The descriptive study aims to focus on evaluating the impact of utilizing

the Early Warning Systems (EWS) Tool. This will be used on patients admitted in

the Adult Care Unit (La Milagrosa Unit) of San Juan de Dios Educational

Foundation Inc (Hospital).

An instructional video from the website of Wellington Hospital will be

utilized as a means of orienting the nurses about the Early Warning System

Secondly, it will be implemented on the unit then, nurses from the unit will be

asked to give scores per determinant depending on degree of abnormality of

retrieved data on the EWS tool.One month will be allotted time for the data

gathering and the implementation of the tool in the unit. Lastly, an evaluation tool

will be provided to determine the impact of utilizing the EWS tool as an

assessment tool in determining early signs of deterioration

The population frame will be 25staff nurses of a unit of the adult care

section. All nurses who met the inclusion criteria will be invited to be the

participants of the study. The regulation parameters are as follows: (1) Nurses

under probationary and regular employment, (2) Nurses of both gender and of

any age will be included in the study, and (3) nurses assigned in La Milagrosa


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Unit. One month will be allotted time for the data gathering. The EWS tool will be

used only for assessment and will not recommend any specific intervention.

SIGNIFICANCE OF THE STUDY:

This study will be designed to evaluate the Impact of utilizing the Early

Warning System Tool.

To the Patients. The Early Warning System tool can be used to monitor a

patient’s progress and provide specific criteria according to their score that will

recognize early deterioration. It will also improve and encourage effective

healthcare and patient teamwork and communication thus improving critical

patient outcomes and patient safety.

To the Nurses. This study will enhance the assessment skills of nurses and

improve clinical judgment especially on critically ill patients. This will also

enhance collaboration within health care team.

To the Hospital Institution. This study will propose to enhance the quality of

healthcare service that will increase customer satisfaction.

To the Future Researchers. The result of the study will encourage future

researchers to conduct studies related to this area of interest by providing the

foundation of knowledge in the assessment of the Early Warning Score tool.

Definition of Terms


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To ensure common understanding between the investigator and the readers,

the following terminologies have been defined:

Patients- all individuals admitted to La Milagrosa Unit

Nurses- Healthcare service provider, whether regularized or under probation

Critically Ill- Patients who are for possible critical care unit transfer, who needs

intensive monitoring, with high dependency

Early Warning System Tool- in this study, the term "checklist" is defined as the

list of things and actions contained in the Early Warning System Tool which

compromises of five (5) determinants: heart rate, systolic blood pessure,

respiratory rate, 4- hour Urine Output, and level of consciousness.

Evaluation Tool- questionnaire to be given to respondents after utilization of

EWS tool for at least 1 month

Length of Experience- number of months or years employed in SJDEFI

Impact- specific effect of the EWS tool utilization to nurses


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CHAPTER II

REVIEW OF RELATED LITERARTURE

Critically Ill patients

Critical illness can be defined as any disease that leads to physiological

instability, where in the patient is at risk of death or disability within a short

amount of time. (British Journal of Hospital Medicine, 2007) According to Society

of Critical Care Medicine, critically ill patients have increased to 5 million in the

United States alone. Multi-organ failure and sepsis were recorded to have

highest occurrence with regard to critical illness and cardiac arrest as the leading

cause of death. Aside from late detection of physiological deterioration, one other

reason for the high rate of critically ill deaths is the late transfers to Intensive

Care Units. This may be because of late recognition of need for transfer or

unavailability of ICU beds. As these findings are presented, the search for

interventions that may lead to better clinical outcomes or prevention of any

untoward effect is also on the rise. (Robertson, Al-Haddad, 2012) Some of the


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interventions tested in other countries to cope up with the statistics are (1)

creation of outreach teams, which comprises of nurses and doctors trained

specifically in resuscitative management of critically ill patients and (2) creating

Early Warning System tools to aid in identifying at risk patients. (Nursing Times,

2002)

Early Warning System

Patients admitted into hospital as a medical emergency are at risk of

deterioration in their clinical condition due to their altered physiological state. The

majority of acute illnesses develop gradually over many hours and are

associated with the early presence of abnormal vital signs in the patient. These

abnormalities reflect failing cardiovascular, respiratory and neurological systems

which are known precursors to a critical event (Gwinutt, 2010).

‘Any patient in hospital may become acutely unwell. However, the

recognition of acute illness is often delayed and its subsequent management

may be inappropriate. This may result in late referral and avoidable admissions

to critical care, and may lead to unnecessary patient deaths, particularly when

the initial standard of care is suboptimal.’ (NICE, 2007)

The early warning score is a physiological scoring system that can help to

identify physiological deterioration. The close monitoring of patients physiological

parameters is the cornerstone in the early detection of critical illness. The Early

Warning Scoring System (EWS) was developed with the aim of providing a

scoring system which could be readily used by healthcare team to help identify


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patients that are at risk for being critically ill and to enhance equity in care that

guarantees early recognition of patients with potential or known to be critical ill

and treat the patients effectively and appropriately. The EWS can be summed up

with six physiological parameters (respiratory rate, heart rate, systolic blood

pressure, temperature, neurological status and oxygen saturations) scored

between 0 - 3 with an total score of three or more triggering the start of the study

of Early Warning Score System (EWS) .

The Early Warning Score should be associated with appropriate

communication between medical and nursing staff. Nurses have played an

important role in preventing adverse events in a patient’s condition. The early

recognition and correct management of physiological abnormality can improve

patient outcomes by reducing the incidence of Adverse events, making nurses’

ability to identify, interpret and act on physiological abnormality a fundamental

factor in preventing occurrences of adverse events. Detection of adverse effect in

physiologic data can require a combination of observational expertise, deduction,

and perception, but there are tools that nurses can use to help such as the Early

Warning System (EWS); however awareness of a person’s ‘usual state’ is the

foundation for recognizing any illness.

Early Warning System (EWS) tool focuses on the collection and

interpretation of objective measurements particularly the basic physciologic

parameters, taking the cues identified by prior research which alert nurses to a


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potential change in the patient’s condition (Atkinson, D., 2013)

Hence, the goal of using Early Warning Systee (EWS) is to prevent harm,

reduce in-hospital cardiac arrests and mortality rates, and facilitate appropriate

use of Critical Care resources, through early recognition and treatment of the

deteriorating patient.

Vital Signs (Early Warning System)

Historically the course of prognosis of patients depends on the competent

workforce, because it compensates any system failure that might occur during

stay in the hospital (Tucker and Edmondson, 2003). Despite this, a landmark

study found the expertise, skills and experience required to care for patients

when they become acutely unwell is not always possessed by staff in general

ward environments (McQuillan et al, 1998).This suggests that even without the

occurrence of the system failure, the patient might not get the appropriate or

maximum care they should receive when their condition worsen. Clinical tool

such as the vital signs are often used in monitoring patients. This tool reflects

how the critically ill patients deteriorate and that early intervention will improve

outcome. However, perception of the senior staff nurses about vital signs

measurement may be basic or skill-based task rather than a knowledge-based

one (Boulanger and Toghill, 2009). Vital signs measurement may, therefore, be

delegated to less qualified or inexperienced nursing staff (Hogan, 2006). But

possessing knowledge, skills and the ability to think critically is the key not only to


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measure vital signs accurately but also to interpret and analyze data in the

context of the patient’s illness and medical treatment (Garcea et al, 2010).

A helpful tool, Early Warning Signs (EWS) was designed to overcome

deterioration in early recognition of shifting of condition of patients from acute to

critical (Goldhill and McNarry, 2004). The data interpretation from assessments is

vital in identifying the level of care a patient requires, providing treatment and

preventing a patient deteriorating from an untoward event(Wheatley, 2006). In

relation to patient outcomes, an early warning system when combined with rapid

response appears to have the potential to reduce cardiac arrests and unplanned

ICU admissions. In a research by University of York (2015), it has been found

that precision of data recording and the calculation of early warning scores can in

turn impact on the accuracy in detecting a patient’s deterioration whereas

inaccuracies of data can lead to delays in identifying patients at risk or critically

ill.

As patients in hospital today are sicker than in the past, nurses can no

longer rely on the traditional five vital signs to determine clinical changes in their

patients. Nurses must not only know how to measure these vital signs accurately,

they must also know how to interpret and act on them. In addition, they must

incorporate additional vital signs when performing assessments of their patients.

In conclusion, it is highly recommended that nurses should use a tool or

method should be used to ensure that nothing is overlooked that may result in a

missed diagnosis or a delay in treatment.


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Early Warning System: Age, Gender and Nature of the Disease

The elders are correlated with higher clinical risk but the interrelation

among age and physiological response is complicated. Hence chronological age

is not congruent with the biological age. The team was not convinced to apply

age on the basis of scoring for National Early Warning Score. (National Early

Warning Score, 2012)

However, a study entitled “Utility of a Single Early Warning Score in

Patients with Sepsis in the Emegency Department” by Corfield, et al (2014)

showed that the median age for 2003 respondents was 72 years old and that

there is no significant difference in age between men and women. Patient

admitted to ICU has a median age of 61 years old and has a high National Early

Warning System NEWS) score than those who are not admitted to Intensive

Care Unit. Within 30 days patient who had a high NEWS score and significantly

older had died. Based on the results of the study, patient aged 50-70 years old

were significantly high risk of dying than those patient aged below fifty years old.

A study entitled “In-hospital mortality and morbidity of elderly medical

patients can be predicted at admission by the Modified Early Warning Score: A

prospective study” revealed that 1107 patients were admitted which were mostly

older than 64 years old. Garnering a result of lesser chances of transfer or death

that proved Early Warning System to be transparent useful tool in predicting a

worse hospital outcome (Cei, et al 2009)


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The progression of chronic disease involves periods of remission mixed

with exacerbations and multiple hospitalizations. Yet there is uncertainty of the

time, frequency and duration of the next episode of decompensation as well as

the ultimate prognosis causing doubts about its management. Observable signs

of decline in physiologic vital signs are often seen 6 to 8 hours prior to cardiac

arrests. According to Schein et al. (1990), 84% of patients had been observed of

clinical deterioration or new complaints within 8 hours of cardiopulmonary arrest;

in 70% of patients, deterioration of either respiratory or mental function was

observed during the time. Early Warning System Score for the use of adult

patients is a standardized assessment and also, a communication method to

recognize and avoid patient decline that may reduce patient mortality and length

of stay thus, developing a standardized tool to gauge the patient and

corresponding algorithm or guide of action steps that guarantees delivery of

patient care. In a review of adult response team from 2007 to 2010, it has

revealed a decrease in numbers of code blue as the number of rapid response

team calls increased. Compared with PEWS (Pediatric Early Warning System);

Early Warning System is a more complicated because it incorporated aspects

above and below the normal or acceptable range and an expanded algorithm for

responding to the scores to include reassessment by the direct care of thee

nurse every hour for 4 consecutive hours to ensure patient stability. If the patient

didn't remain stable for 4 consecutive hours, the team considered transferring the

patient to a higher level of care.


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Therefore, Clinical deterioration can occur at any stage of a patient’s

illness; however, there may be certain periods when a patient is vulnerable to

deterioration such as during the onset of illness, during medical interventions and

during recovery. Patients who are at risk of deteriorating may be identified prior to

having serious adverse event by changes in their physiological data. Timely

interpretation and escalation of recognized deterioration is of crucial importance

in minimizing the likelihood of serious and adverse events including cardiac

arrest and death.

Early Warning System in Adult Care Section

Every year, 13 million people, are admitted to acute hospitals in England and

Wales. Inevitably, some of these people will die as a result of their illness.

(National Patient Safety Agency, 2007) In general wards, there is a ratio of one

nurse to more patients wherein nurses cater a large number of patients

compared to intensive care unit. Nurses can be called by patient through buzzer

when they need attention and help. Prioritization is a key component in providing

nursing care in the ward. Dependencies of patients are kept into minimum

especially those who can perform self-care. (Orgtalk, 2013)

In research by Fligelstone, et al. (2005), surgical patients referred in an

intensive care unit (ICU) had significant physiological abnormalities that would

have triggered an Early Warning Score for a mean of 12 hours prior to being

referred to medical staff. Physiological data seem to suggest that deterioration of


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patients on general wards is predictable on the basis of a structured analysis of

physiological bed-side observations.

A study by Godhill, et al (1999) hypothesized that patients admitted to ICU

are often seriously ill before ICU admission. If patients can be recognized and

treated earlier, it may be possible to decrease mortality and the ICU stay of

survivors. Data suggest that respiratory rate, heart rate and the adequacy of

oxygenation are the most important physiological indicators of a critically ill ward

patient. The level of consciousness and presence of renal failure may also be

important indicators. Abnormal values of selected physiological measurements

may be useful as an objective indication that patients are at risk.

Early Warning Score tool is an important tool that warns physicians and the

healthcare team about the health status of the patient. This will help lessen ICU

transfers. Studies revealed that there is a positive relationship between the

magnitude of changed scores of critical patients and need for admission to ICU.

In relation to this study, patient came from the ward have a high morbidity before

they are admitted to ICU with the EWS score of above 3 points in a 70% of the

population with an average above 5 points. Within 72 hours before admission to

ICU dead patients has a significant increase in their EWS scores. As early as

possible using the EWS can prevent clinical deterioration, there is a direct

relation between the critical score of EWS and increasing morbidity or mortality

(Tavares et al,2008)

Patient admitted in the ICU with the EWS score of greater than six has a

significantly higher mortality and it is the independent predictor of death in ICU.


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The Scoring of the EWS on admission to ICU is the same with the Simplified

Acute Physiology Score III and the Sequential Organ Failure Assessment score

on admission. The result of the study reveals that EWS is a useful tool in

assessing patient in the ICU on a 30 day stay and mortality. (Reini et al, 2012)

Studies also suggest that clinical deterioration of patients on general

hospital wards is often preceded by changes in physiological observations that

are recorded by clinical staff six to 24 hours prior to a serious adverse event

(Kause, 2004). In the study by National Patient Safety Agency (2007), Of the 64

cases of patient deterioration identified in 2005 in acute hospital settings, it was

reported that in 14 cases, no observations were made for a prolonged period

prior to death and changes in vital signs were not detected. While in 30 cases,

despite the recording of vital signs, it was reported that there was no recognition

of clinical deterioration and/or no action taken. And the rest of the cases,

deterioration were recognized and assistance was sought.

Early Warning Score is a simple procedure based on bedside observations

that have been recommended to identify patients at risk on general hospital

wards. This approach classifies critically ill patients by need or level of care

required according to the complexity of acute care on a scale of zero where

needs can be met through a normal ward; to three where a patient requires

advanced respiratory support in ICU); and not based by their geographical

boundaries (DOH, 2000).


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In conclusion, It is found that by identifying patients who are deteriorating

and by acting early, staff and their organizations can make a real difference. They

can also enhance patient safety by improving systems to resuscitate patients

when they have a cardiac arrest.

Impact of Early Warning System (EWS) on Nurses

A fundamental aspect of practice every clinician must grasp is how to

recognize changes in the condition of their patient and most importantly what

they should do to determine if the patient’s condition is deteriorating. Without this

fundamental practice being understood by all with clinical responsibilities,

patients may well suffer and even die as a consequence.

The main purpose of early warning score systems is to ensure early

identification and response to the deteriorating patient, and ultimately to improve

patient safety. It is important to evaluate it in a hospital context to identify

changes that might be required to optimize performance. Its significance in early

detection and activation of medical response has prompted health services in

Canada, Australia and the UK to implement early warning score systems.

(Patterson., et al, 2011).

In a study by Green A, et al. (2006), as a primary user of the clinical


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marker referral tool or Early Warning System (EWS) it is important to explore the

healthcare team’s perception, attitudes, and perceived understanding of the

implemented tool to assist in the early identification of unstable patients. Overall,

the responses of the healthcare team were positive to the clinical marker tool or

Early Warning System (EWS), offering clear guidelines for staff to respond to the

patient's clinical condition and contact the medical staff and the ICU liaison team

as appropriate.

Nurses play a central role in implementing an early warning score system

and it is important to capture their ‘voice’ when evaluating the effectiveness of the

tool. In a study by Cox, A., et al (2015) early warning scoring systems are simple

yet several studies reveal problems such as failure to recognize deteriorating

patients or delayed response to them, which suggest that implementation of this

tool can highlight shortcomings in healthcare delivery.

Studies suggest that problems in delay recognition of deteriorating

patients originated from a lack of standardized tool that provides observation

chart and staff training. (Patterson, et al., 2011) Whereas, other studies suggest

that it is staff- related, wherein nurses lack confidence in calling for help when

they think patients are unwell and therefore are reluctant to activate medical

teams. (Cox., et al, 2015)

The evaluation tool was designed to gauge the nurses’ experiences of


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using the Early Warning System with regard to its effect on clinical decision-

making and helping to identify problems in clinical practice. While it was

considered to enhance the nurse’s role in clinical decision-making, participants

used it to supplement rather than replace clinical judgment. As experienced

nurses, they know that NEWS has limitations.

In conclusion, Participants found that Early Warning System helped them

identify patients who needed to be monitored more closely and they considered

that it was a useful decision-making tool for newly qualified and student nurses.

They found the tool helpful but in some cases, for example in patients with

hypertension and acute myocardial infarction, they also used their clinical

judgment to activate a medical review and did not rely solely on Early Warning

System


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CHAPTER III

METHODOLOGY

This chapter presents the procedures and processes through which this

study is instituted. This chapter covers the research design, sample, research

instruments, the data gathering procedures and statistical tools applied.

Research Design

This study will assess the impact of utilizing the Early Warning System

(EWS) tool in the practice of nurses in La Milagrosa Unit at San Juan de Dios

Educational Foundation, Inc. (Hospital). It will utilize the quantitative non-

experimental, descriptive correlational research design.

A descriptive research gathers pertinent data that can be used for

statistical conclusion on the target audience through data analysis. Correlational

type of descriptive research design seeks to determine the extent of relationship


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between variables by determining how changes in one variable relate to

changes in another variable. It discovers how the phenomena under study are

related.

The variables of the study are quantifiable for the reason that the

investigators will utilize a checklist tool, which is the Early Warning System and

an evaluation tool to determine the impact of utilizing the Early Warning System

tool.

The Population Frame

The respondents of the study consist of all the staff nurses including those

under probationary status and regular employment assigned in La Milagrosa

Unit. Currently La Milagrosa Unit has 25 staff nurses.

Sampling Technique

The sampling technique that will be utilized in this study is the Purposive

Sampling, which is a non-probability sampling technique. Non-probability

Purposive sampling is a sampling technique where respondents are selected

based on the criteria set by the investigators which on this study are the

following: (1) Nurses under probationary status and regular employment, (2)

Nurses of both gender and of any age will be included in the study, and (3)

nurses assigned in La Milagrosa Unit.

Setting


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The study shall take place in San Juan De Dios Educational Foundation

Hospital, under the Adult Care Section, specifically, La Milagrosa Unit.

Research Instrumentation

The research instrument that will be utilized in this study is the Early Warning

System Checklist. There are five (5) parameters for the Early Warning System

checklist namely: Respiratory Rate, Systolic Blood Pressure, Heart Rate, 4 Hour

Urine Output, and Level of Consciousness. For each parameter, a score from 0-3

may be given depending how far from the normal range the data gathered is. The

researchers of this study took into consideration in asking for permission of the

author via email correspondence regarding the use of the tool.

The research instrument that will be used as the evaluation tool composes of 17

questions that will determine the impact of utilizing the Early Warning System tool

in the nursing practice.The researchers of this study will again take into

consideration asking for permission from the author via email correspondence

regarding the use of the tool.

Data Gathering Procedure

After garnering the approval of the institutional review board, the

researchers will ask for the approval of the unit manager of the La Milagrosa

Unit. The purpose of the study and other important details will be disclosed and

explanation on how the data gathering will commence.


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A pilot study with 10 respondents will be conducted to assess the

feasibility of the study. A general introduction to the tool will be given to the

nurses of each unit to be utilize, so that there will be uniform understanding of the

study. The Early Warning System tool will be used by all nurses of the La

Milagrosa Unit. The EWS tool will be used on all patients handled by the nurse.

After a month we will conduct an evaluation regarding the impact of utilizing the

EWS tool through a questionnaire.


Conduction of pilot study

Approval from unit managers after explanation of study purpose and process

Utilization of EWS tool twice per 8-hour shift, per patient

General orientation for nurses in units to be utilized in study including introduction to the Early Warning System tool

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Statistical Treatment

Statistical treatment of data is essential in order to mold the data with the

goal of discovering and making appropriate conclusion from the raw data

collected.

In the study, the percentage and frequency distribution, weighted mean,

and Spearman’s Rho correlation test are use to interpret and analyze the results

of the study. Statistical software called Statistical Package for Social Sciences

was used to analyze the gathered data.

1. Percentage and Frequency distribution will be used to summarize


Evaluation of the impact of utilizing the Early Warning System tool by the nurse

Collation and organization of EWS tools used

Collation and organization of the evaluation tools

Evaluation of the data gathered

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respondents’ profile characteristics.

2. The general weighted mean will be utilized extensively in descriptive

statistical analysis of data gathered among respondents.

3. Spearman rho correlation test will be utilized to determine the significant

relationship between the profile characteristics of the nurse and the evaluation

tool scores.

Ethical Consideration of Research

The purpose of the study will be discussed to the respondents. Before the

study was conducted, the researchers will assure the respondents that results

will be treated with confidentiality. A letter will be given to the respondents stating

the objectives and purpose of the study.

An informed consent will be secured from the respondents after

explaining the process of the study. Respondents have the right to autonomy,

he/she could decide whether to participate or not at any given time during the

whole study.


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References:

Alasdair R Corfield, Fiona Lees, Ian Zealley, Gordon Houston, Sarah Dickie, Kirsty Ward, Crawford McGuffie “Utility of a Single Early Warning Score in Patients With Sepsis in the Emergency Department”, Emergeny Medicine Journal, 2014;31(6):482-487.

Atkinson, D. (2013). Nursing Observation and Assessment of Patients in the Acute Medical Unit. Professional Doctorate, University of Salford, Salford, United Kingdom.

Cei, M, Bartolomei, C. and Mumoli, N., “In-hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score: a prospective study”, International Journal of Clinical Practice, 2009, Volume 63, Issue 4, pages 591-595

Chartash, D. (2013). An Analysis of Rapid Response Team Calling Algorithms for Clinical Deficit Evaluation. Degree of Master of Health Science. University of Toronto, Ontario, Canada


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Considine, J., &Botti, M. (2004). Who, when and where? Identification of patients at risk of an in‐hospital adverse event: Implications for nursing practice. International journal of nursing practice, 10(1), 21-31.

Cox, A., & Elliott, N. (2015). Early Warning Scores: A Sign of Deterioration in Patients and Systems. Nursing Management, 22(1), 26-31.doi: http://dx.doi.org/10.7748/nm.22.1.26.e1337

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