Physiological risk factors, early warning scoring systems and organizational changes.

Currently, medical and surgical wards tend to have a higher number of sicker and more dependent patients. There is also a growing recognition that several indicators of acute deterioration are being missed, leading to adverse consequences for the patients. As a result, many initiatives have been designed to try to reduce these consequences, including the development of early warning scoring or track and trigger systems and medical response and critical care outreach teams. This paper briefly discusses the risk factors associated with acute deterioration, the use of early warning scoring or track and trigger systems and the role of outreach teams. The aim of this paper is to discuss the development and subsequent implementation of early warning scoring systems (EWS) or track and trigger systems. It will also discuss the associated organizational changes; the main organizational change discussed will be the introduction outreach teams. For this paper, a pragmatic search strategy was implemented using the following terms: early warning score and scoring, track and trigger systems, decision-making tools, critical care outreach and medical emergency teams. The databases used included CINHAL (1997-2007), Medline, Blackwell Synergy and Science Direct, as these would enable the retrieval of relevant literature in the area of triggering of response to acute deterioration in clinical condition. A 10-year limit was initially set, although review of the literature identified resulted in a widening of this to include some of the relevant (and occasionally more dated) literature referred to in these papers. A total of 645 were accessed; of these 135 were retrieved as they appeared to meet the inclusion criteria, but only 35 have been included in this review. The term decision-making tools accounted for the largest number (500), but most of these were irrelevant. EWS are not always used to their full potential, raising the question of their impact. The impact of outreach teams and medical emergency teams has yet to be fully defined. For clinical practice, this means that care must be taken when developing and implementing these changes. The rigour of the development process needs to be considered along with reflection upon how to best meet local requirements.