Capturing early signs of deterioration: the dutch‐early‐nurse‐worry‐indicator‐score and its value in the Rapid Response System

Aims and objectives To determine the predictive value of individual and combined dutch‐early‐nurse‐worry‐indicator‐score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point. Background Dutch‐early‐nurse‐worry‐indicator‐score comprises nine indicators underlying nurses’ ‘worry’ about a patient's condition. All indicators independently show significant association with unplanned intensive care/high dependency unit admission or unexpected mortality. Prediction of this outcome improved by adding the dutch‐early‐nurse‐worry‐indicator‐score indicators to an Early Warning Score based on vital signs. Design An observational cohort study was conducted on three surgical wards in a tertiary university‐affiliated teaching hospital. Methods Included were surgical, native‐speaking, adult patients. Nurses scored presence of ‘worry’ and/or dutch‐early‐nurse‐worry‐indicator‐score indicators every shift or when worried. Vital signs were measured according to the prevailing protocol. Unplanned intensive care/high dependency unit admission or unexpected mortality was the composite endpoint. Percentages of ‘worry’ and dutch‐early‐nurse‐worry‐indicator‐score indicators were calculated at various Early Warning Score levels in control and event groups. Entering all dutch‐early‐nurse‐worry‐indicator‐score indicators in a multiple logistic regression analysis, we calculated a weighted score and calculated sensitivity, specificity, positive predicted value and negative predicted value for each possible total score. Results In 3522 patients, 102 (2·9%) had an unplanned intensive care/high dependency unit admissions (n = 97) or unexpected mortality (n = 5). Patients with such events and only slightly changed vital signs had significantly higher percentages of ‘worry’ and dutch‐early‐nurse‐worry‐indicator‐score indicators expressed than patients in the control group. Increasing number of dutch‐early‐nurse‐worry‐indicator‐score indicators showed higher positive predictive values. Conclusions Dutch‐early‐nurse‐worry‐indicator‐score indicators alert in an early stage of deterioration, before reaching the trigger threshold to call a rapid response team and can improve interdisciplinary communication on surgical wards during regular rounds, and when calling for assistance. Relevance to clinical practice Dutch‐early‐nurse‐worry‐indicator‐score structures communication and recording of signs known to be associated with a decline in a patient's condition and can empower nurses to call assistance on the ‘worry’ criterion in an early stage of deterioration.