Una Kyriacos


Background: Routine monitoring of patients’ clinical and physiological status by nurses includes the use of vital signs (observations) charts for recording findings. Charts that incorporate early warning score (EWS) systems are designed to ‘track’ signs of deterioration and ‘trigger’ a rapid response. Published studies of EWS systems are of limited benefit if reporting of these studies is inadequate. Reporting guidelines are recommended to improve the quality of reporting.

Objective: To assess the adequacy of reporting studies on EWS systems.

Methods: All study designs published between 1 May 2007 and 23 May 2015 describing the use of EWS systems for detecting deterioration in adult patients on general medical and surgical wards were included. Data extraction was undertaken by one researcher.

Results: Of the 657 references identified from search terms, 596 articles were excluded leaving 61 articles for assessment. Most studies were published in non-nursing journals (47/61, 77.0%). Six of the 61 (9.8%) studies were reviews. The remaining 55 clinical studies on the use of EWS/MEWS systems were mostly observational (46/55, 83.6%) rather than experimental (9/55, 16.4%).

Reporting guidelines were used in 9.8% (6/61) of reviewed studies. Only the reviews but no clinical studies reported a search strategy. Electronic searches included mostly CINAHL (5/6, 83.3%), MEDLINE and The Cochrane Library (4/6, 66.7%). No meta-analyses were performed. Inclusion and exclusion criteria and reasons for exclusion of references were well reported in the reviews.

The most frequently reported range of physiological parameters (12/61, 19.7%) were respiratory rate, oxygen saturation, supplemental oxygen, heart rate, systolic blood pressure, temperature and level of consciousness.

Conclusion: Reporting of published studies on EWS systems reviewed for this critical appraisal, with the exception of reviews, was inadequate as most did not use reporting guidelines, limiting the use of study findings for developing clinical guidelines and in further research. 


adult patients, deterioration, early warning score, general wards, modified early warning score, observations, vital signs

Full Text:



ALAM, N., HOBBELINK, E. L., VAN TIENHOVEN, A. J., VAN DE VEN, P. M., JANSMA, E. P. & NANAYAKKARA, P. W. 2014. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation, 85, 587-94.

ALTMAN, D. 2013. Critical appraisal checklists and reporting guidelines The EQUATOR Network workshop. WHO, Geneva.

CALZAVACCA, P., LICARI, E., A., T. & ., E. A. 2010. The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes - a follow-up study Resuscitation 81 31 – 35.

CALZAVACCA, P., LICARI, E., TEE, A. & AL, E. 2008. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care Med, 34, 2112 – 2116.

CAMPBELL, M., ELBOURNE, D. & ALTMAN, D. 2004. CONSORT statement: extension to cluster randomised trials. British Medical Journal, 328, 702 - 8.

CHALMERS, I. & GLASZIOU, P. 2009. Avoidable waste in the production and reporting of research evidence. Lancet, 374, 86–89.

CIOFFI, J. 2000a. Recognition of patients who require emergency assistance: a descriptive study. Heart & Lung : the Journal of Critical Care, 29, 262-268.

CIOFFI, J. 2000b. Nurses' experiences of making decisions to call emergency assistance to their patients. Journal of Advanced Nursing, 32, 108-114.

DECHARTRES, A., CHARLES, P., HOPEWELL, S., RAVAUD, P. & ALTMAN, D. G. 2011. Reviews assessing the quality or the reporting of randomized controlled trials are increasing over time but raised questions about how quality is assessed. J Clin Epidemiol, 64, 136-44.

DISSEMINATION, C. F. R. A. January 2009. Systematic Reviews. CRD’s guidance for undertaking reviews in health care.

GRIMES, D. A. & SCHULZ, K. F. 2002. An overview of clinical research: the lay of the land. The Lancet, 359, 57-61.

HIRST, A. & ALTMAN, D. G. 2012. Are Peer Reviewers Encouraged to Use Reporting Guidelines? A Survey of 116 Health Research Journals. PloS ONE, 7, e35621.

HOGAN, J. 2006. Why don't nurses monitor the respiratory rates of patients? British Journal of Nursing,, 15, 489-492.

JOHNSTONE, C. C., RATTRAY, J. & MYERS, L. 2007. Physiological risk factors, early warning scoring systems and organizational changes. Nursing in Critical Care, 12, 219-224.

KISIEL, M. & PERKINS, C. 2006. Nursing observations: knowledge to help prevent critical illness. British Journal of Nursing,, 15, 1052-1056.

KYRIACOS, U., JELSMA, J., JAMES, M. & JORDAN, S. 2014. Monitoring vital signs: development of a modified early warning scoring (MEWS) system for general wards in a developing country. PLoS One, 9, e87073.

KYRIACOS, U., JELSMA, J., JAMES, M. & JORDAN, S. 2015. Early warning scoring systems versus standard observations charts for wards in South Africa: a cluster randomized controlled trial. Trials, 16, 103.

KYRIACOS, U., JELSMA, J. & JORDAN, S. 2011. Monitoring vital signs using early warning scoring systems: a review of the literature. Journal of Nursing Management, 19, 311-330.


MOHER, D. 2009. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. Annals of Internal Medicine, 151, W-65-W-94.

MAPP, I. D., DAVIS, L. L. & KROWCHUK, H. 2013. Prevention of Unplanned Intensive Care Unit Admissions and Hospital Mortality by Early Warning Systems. Dimensions of Critical Care Nursing, 32, 300-309.

MCNEILL, G. & BRYDEN, D. 2013. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation, 84, 1652-67.

MELLO, M. M., STUDDERT, D. M. & BRENNAN, T. A. 2003. The New Medical Malpractice Crisis. New England Journal of Medicine, 348, 2281-2284.

MOHER, D., COOK, D. J., EASTWOOD, S., OLKIN, I., RENNIE, D. & STROUP, D. F. 1999. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet, 354, 1896-1900.

MOHER, D., LIBERATI, A., TETZLAFF, J., ALTMAN, D. & GROUP, F. T. P. 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. British Medical Journal, 339, b2535.

MONAGHAN, T. 2015. A critical analysis of the literature and theoretical perspectives on theory–practice gap amongst newly qualified nurses within the United Kingdom. Nurse Education Today, 35, e1-e7.

NHS NPSA. 2007. Safer Care for the Acutely Ill Patient [Online]. Available: [Accessed 2008/07/10

ODELL, M., VICTOR, C. & OLIVER, D. 2009. Nurses' role in detecting deterioration in ward patients: systematic literature review. Journal of Advanced Nursing, 65, 1992-2006.

REASON, J. 2000. Human error: models and management. British Medical Journal., 320, 768.

RIEGELMAN, R. K. C. A., RINKE, M.L. (2013). STUD 2013. Studying a study & testing a test: Reading evidence-based health research

Riegelman, R.K. Contributing author, Rinke, M.L. (2013). Studying a study & testing a test: Reading evidence-based health research (). Philadelphia: Wolvers Kluwer. Available: [2015, 12 December], Philadelphia: Wolvers Kluwer.

ROYAL COLLEGE OF PHYSICIANS 2012. National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS. Report of a working party. London:RCP: Royal College of Physicians.

RYLANCE, J., BAKER, T., MUSHI, E. & MASHAGA, D. 2009. Use of an early warning score and ability to walk predicts mortality in medical patients admitted to hospitals in Tanzania. Trans R Soc Trop Med Hyg, 103, 790-4.

SIMERA, I., MOHER, D., HIRST, A., HOEY, J., SCHULZ, K. & AL., E. 2010. Transparent and accurate reporting increases reliability, utility, and impact of your research: reporting guidelines and the EQUATOR Network. BMC Med, 8, 24.

SMITH, M. E., CHIOVARO, J. C., O'NEIL, M., KANSAGARA, D., QUINONES, A. R., FREEMAN, M., MOTU'APUAKA, M. L. & SLATORE, C. G. 2014. Early warning system scores for clinical deterioration in hospitalized patients: a systematic review. Ann Am Thorac Soc, 11, 1454-65.

STORM-VERSLOOT, M. N., VERWEIJ, L., LUCAS, C., LUDIKHUIZE, J., GOSLINGS, J. C., LEGEMATE, D. A. & VERMEULEN, H. 2014. Clinical Relevance of Routinely Measured Vital Signs in Hospitalized Patients: A Systematic Review. Journal of Nursing Scholarship, 46, 39-49 11p.

SUBBE, C., DAVIES, R., WILLIAMS, E., RUTHERFORD, P. & GEMMELL, L. 2003. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia, 58, 797 - 802.

TANNER, C. A. 2006. Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing Education, 45, 204-211.

WALCHER, F., KULLA, M., KLINGER, S., ROHRIG, R., WYEN, H., BERNHARD, M., GRAFF, I., NIENABER, U., PETERSEN, P., HIMMELREICH, H., SCHWEIGKOFLER, U., MARZI, I. & LEFERING, R. 2012. [Standardized documentation in emergency departments with the core dataset of the DIVI]. Unfallchirurg, 115, 457-63.

WILSON, R. M., HARRISON, B. T., GIBBERD, R. W. & HAMILTON, J. D. 1999. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. The Medical Journal of Australia, 170, 411-415.

ZHU, X., LI, T. & LIU, M. 2015. [Evaluation and analysis of monitoring and early warning functions of the occupational disease reporting system in China]. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 33, 422-6.

ZIMLICHMAN, E., SZYPER-KRAVITZ, M., UNTERMAN, A., GOLDMAN, A., LEVKOVICH, S. & SHOENFELD, Y. 2009. How is My Patient Doing? Evaluating Hospitalized Patients Using Continuous Vital Signs Monitoring. Israeli Medical Association Journal, 11, 382-384.



  • There are currently no refbacks.

Copyright (c) 2018 Trends in Nursing

ISSN 2313-8467 (on-line)      Creative Commons License - CC BY 4.0

Powered by OJS and hosted by Stellenbosch University Library and Information Service since 2014.


This journal is hosted by the SU LIS on request of the journal owner/editor. The SU LIS takes no responsibility for the content published within this journal, and disclaim all liability arising out of the use of or inability to use the information contained herein. We assume no responsibility, and shall not be liable for any breaches of agreement with other publishers/hosts.

SUNJournals Help