Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration

Aust Crit Care. 2017 Jul;30(4):211-218. doi: 10.1016/j.aucc.2016.10.003. Epub 2016 Nov 15.


Introduction: Early warning systems (EWS) were developed as a means of alerting medical staff to patient clinical decline. Since 85% of severe adverse events are preceded by abnormal physiological signs, the patient bed-side vital signs observation chart has emerged as an EWS tool to help staff identify and quantify deteriorating patients. There are three broad categories of patient observation chart EWS: single or multiple parameter systems; aggregated weighted scoring systems; or combinations of single or multiple parameter and aggregated weighted scoring systems.

Objective: This scoping review is an overview of quantitative studies and systematic reviews examining the efficiency of the adult EWS charts in the recognition of in-hospital patient deterioration.

Method: A broad search was undertaken of peer-reviewed publications, official government websites and databases housing research theses, using combinations of keywords and phrases.

Data sources: CINAHL with full text; MedLine, PsycINFO, MasterFILE Premier, GreenFILE and ScienceDirect. Also, the Cochrane Library database, Department of Health government websites and Ethos, ProQuest and Trove databases were searched.

Exclusions: Paediatric, obstetric and intensive care studies, studies undertaken at the point of hospital admission or pre-admission, non-English publications and editorials.

Results: Five hundred and sixty five publications, government documents, reports and theses were located of which 91 were considered and 21 were included in the scoping review. Of the 21 publications eight studies compared the efficacy of various EWS and 13 publications validated specific EWS.

Conclusions: There is low level quantitative evidence that EWS improve patient outcomes and strong anecdotal evidence that they augment the ability of the clinical staff to recognise and respond to patient decline, thus reducing the incidence of severe adverse events. Although aggregated weighted scoring systems are most frequently used, the efficiency of the specific EWS appears to be dependent on the patient cohort, facilities available and staff training and attitude. While the review demonstrates support for EWS, researchers caution that given the contribution of human factors to the EWS decision-making process, patient EWS charts alone cannot replace good clinical judgment.

Keywords: Early warning systems; In-hospital patients; Patient deterioration; Patient outcomes; Preventable mortality; Severe adverse events; Track-and-trigger; Unplanned ICU admission.

Publication types

  • Review

MeSH terms

  • Adult
  • Clinical Competence*
  • Clinical Deterioration*
  • Critical Illness*
  • Decision Making
  • Hospitalization
  • Humans
  • Monitoring, Physiologic / instrumentation*
  • Vital Signs