title: Evaluation of the effects of implementing an electronic early warning score system: protocol for a stepped wedge study.
abstract: BACKGROUND
  An Early Warning Score is a clinical risk score based upon vital signs intended to aid recognition of patients in need of urgent medical attention. The use of an escalation of care policy based upon an Early Warning Score is mandated as the standard of practice in British hospitals. Electronic systems for recording vital sign observations and Early Warning Score calculation offer theoretical benefits over paper-based systems. However, the evidence for their clinical benefit is limited. Previous studies have shown inconsistent results. The majority have employed a "before and after" study design, which may be strongly confounded by simultaneously occurring events. This study aims to examine how the implementation of an electronic early warning score system, System for Notification and Documentation (SEND), affects the recognition of clinical deterioration occurring in hospitalised adult patients.
  
  
  METHODS
  This study is a non-randomised stepped wedge evaluation carried out across the four hospitals of the Oxford University Hospitals NHS Trust, comparing charting on paper and charting using SEND. We assume that more frequent monitoring of acutely ill patients is associated with better recognition of patient deterioration. The primary outcome measure is the time between a patient's first observations set with an Early Warning Score above the alerting threshold and their subsequent set of observations. Secondary outcome measures are in-hospital mortality, cardiac arrest and Intensive Care admission rates, hospital length of stay and system usability measured using the System Usability Scale. We will also measure Intensive Care length of stay, Intensive Care mortality, Acute Physiology and Chronic Health Evaluation (APACHE) II acute physiology score on admission, to examine whether the introduction of SEND has any effect on Intensive Care-related outcomes.
  
  
  CONCLUSIONS
  The development of this protocol has been informed by guidance from the Agency for Healthcare Research and Quality (AHRQ) Health Information Technology Evaluation Toolkit and Delone and McLeans's Model of Information System Success. Our chosen trial design, a stepped wedge study, is well suited to the study of a phased roll out. The choice of primary endpoint is challenging. We have selected the time from the first triggering observation set to the subsequent observation set. This has the benefit of being easy to measure on both paper and electronic charting and having a straightforward interpretation. We have collected qualitative measures of system quality via a user questionnaire and organisational descriptors to help readers understand the context in which SEND has been implemented.
authors: Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. timothy.bonnici@ndm.ox.ac.uk.
authors: Timothy
authors: T
authors: Bonnici
authors: Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK. stephen.gerry@csm.ox.ac.uk.
authors: Stephen
authors: S
authors: Gerry
authors: Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK. D.C.Wong@leeds.ac.uk.
authors: David
authors: D
authors: Wong
authors: Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. julia.knight@ouh.nhs.uk.
authors: Julia
authors: J
authors: Knight
authors: Kadoorie Centre for Critical Care Research and Education, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. peter.watkinson@ndcn.ox.ac.uk.
authors: Peter
authors: P
authors: Watkinson
mesh_terms: D003422:Critical Care / Q000379:methods*; D018450:Disease Progression; D006305:Health Status Indicators; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods*; D017063:Outcome Assessment, Health Care; D012306:Risk; D013222:State Medicine