title: Nurses' 'worry' as predictor of deteriorating surgical ward patients: A prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score.
abstract: BACKGROUND
  Nurses' 'worry' is used as a calling criterion in many Rapid Response Systems, however it is valued inconsistently. Furthermore, barriers to call the Rapid Response Team can cause delay in escalating care. The literature identifies nine indicators which trigger nurses to worry about a patient's condition.
  
  
  OBJECTIVE
  The objective of this study is to determine the significance of nurses' 'worry' and/or indicators underlying 'worry' to predict unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality among surgical ward patients.
  
  
  METHODS
  A prospective cohort study.
  
  
  METHODS
  A 500-bed tertiary University affiliated teaching hospital.
  
  
  METHODS
  Adult, native speaking surgical patients, admitted to three surgical wards (traumatology, vascular- and abdominal/oncological surgery). We excluded patients with a non-ICU policy or with no curative treatment. Mentally incapacitated patients were also excluded.
  
  
  METHODS
  We developed a new clinical assessment tool, the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) based on signs underlying 'worry'. Nurses systematically scored their 'worry' and the DENWIS once per shift or at any moment of 'worry'. DENWIS measurements were linked to routinely measured vital signs. The composite endpoint was unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality. The DENWIS-indicators were included in a univariate and multivariate logistic regression analysis, subsequently inserting 'worry' and the Early Warning Score into the model. We calculated the area under the receiver-operating characteristics curve.
  
  
  RESULTS
  In 3522 patients there were 102 (2.9%) patients with unplanned Intensive Care Unit/High Dependency Unit-admissions or unexpected mortality. 'Worry' (0.81) and the DENWIS-model (0.85) had a lower area under the receiver-operating characteristics curve than the Early Warning Score (0.86). Adding 'worry' and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs.
  
  
  CONCLUSIONS
  In this single-center study we showed that adding the Early Warning Score based on vital signs to the DENWIS-indicators improves prediction of unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality.
authors.affiliation: Gelderse Vallei Hospital, Care Division, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands; Radboud university medical centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ H), Geert Grooteplein 21 (route 114), Nijmegen, The Netherlands. Electronic address: douwg@zgv.nl.
authors.forename: Gooske
authors.initials: G
authors.lastname: Douw
authors.affiliation: Radboud university medical centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ H), Geert Grooteplein 21 (route 114), Nijmegen, The Netherlands. Electronic address: Getty.Huisman-deWaal@radboudumc.nl.
authors.forename: Getty
authors.initials: G
authors.lastname: Huisman-de Waal
authors.affiliation: Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands. Electronic address: ZantenA@zgv.nl.
authors.forename: Arthur R H
authors.initials: AR
authors.lastname: van Zanten
authors.affiliation: Radboud university medical centre, Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands. Electronic address: Hans.vanderHoeven@radboudumc.nl.
authors.forename: Johannes G
authors.initials: JG
authors.lastname: van der Hoeven
authors.affiliation: University of Southampton, Faculty of Health Sciences, NIHR CLAHRC (Wessex), Level A, (MP11) South Academic Block, Southampton General Hospital, Tremona Road, SO16 6YD, United Kingdom; Radboud university medical centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ H), Geert Grooteplein 21 (route 114), Nijmegen, The Netherlands. Electronic address: L.Schoonhoven@soton.ac.uk.
authors.forename: Lisette
authors.initials: L
authors.lastname: Schoonhoven
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009741:Nursing Staff, Hospital; D011446:Prospective Studies; D013514:Surgical Procedures, Operative
keywords: DENWIS; Deterioration; Early recognition; Hospital Rapid Response Team; Intensive Care Unit; Nurses; Worry