Background
In-hospital patients are often at risk for acute deterioration, which can lead to many adverse outcomes including death. It is a challenge to identify these patients in time and to provide proper care to prevent these outcomes. For this goal, many hospitals employ an Early Warning Score (EWS).
We aimed to introduce an integrated EWS to our 1100 bed hospital to improve the identification of patients at risk for acute deterioration, and to find a way to empower our nurses in providing optimal care for these patients.

Methods
- Development of new EWS using available literature: the EWS-MB. 
- Phase 1: Nurses on two surgical and two medical wards scored their patients, also reporting on their clinical perception of the patient and their idea of appropriate clinical actions.
- Assessment of clinical outcome of the patients scored. 
- Phase 2: Development of treatment guidelines based on the outcome of phase 1. 
- Gathering of new measurements and feedback.
Interventions were defined as: call for rapid response team, the need for resuscitation, admission to the ICU, immediate (revision) surgery, or death.

Results
In total 897 measurements were taken of 365 patients. In 93.4% of all cases nurses agreed with the recommended treatment guidelines for their patient. An EWS-MB score ≥ 4 identified 100% of all patients that had an intervention where nurses' assesment only identified 85.7% of patients that had an intervention. However, of all patients that scored ≥ 4 only 53.7% had an intervention where nurses correctly predicted whether a patient required an intervention or not in 83.9% of these cases.

Conclusions
A score of ≥ 4 on the  EWS-MB is useful in identifying patients who are at risk for deterioration and who might be missed or diagnosed too late based on nurses’ assessment alone. 
However, nurses’ clinical assessment of patients that score ≥ 4 on the EWS-MB is more accurate in predicting the actual need for intervention than just using a score of ≥ 4. 
A combination of routinely scoring the EWS-MB and empowering nurses to take appropriate action for patients identified as being at risk, with the help of treatment guidelines, can therefore be an efficient strategy to provide optimal treatment.
Since our treatment guidelines were developed with nurses’ feedback and have a high rate of approval, we are convinced these will help in empowering nurses to provide proper care for our patients. 

Take Home Message
A combination of an EWS and empowering nurses to take appropriate action based on their clinical perception of patients can be a good method of identifying and taking care of patients at risk for acute deterioration.

6 - Introducing a nurse-empowered Early Warning Score to the Elisabeth-TweeSteden hospital.