title: Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the Rapid Response System.
abstract: OBJECTIVE
  To determine the predictive value of individual and combined dutch-early-nurse-worry-indicator-score indicators at various Early Warning Score levels, differentiating between Early Warning Scores reaching the trigger threshold to call a rapid response team and Early Warning Score levels not reaching this point.
  
  
  BACKGROUND
  Dutch-early-nurse-worry-indicator-score comprises nine indicators underlying nurses' 'worry' about a patient's condition. All indicators independently show significant association with unplanned intensive care/high dependency unit admission or unexpected mortality. Prediction of this outcome improved by adding the dutch-early-nurse-worry-indicator-score indicators to an Early Warning Score based on vital signs.
  
  
  METHODS
  An observational cohort study was conducted on three surgical wards in a tertiary university-affiliated teaching hospital.
  
  
  METHODS
  Included were surgical, native-speaking, adult patients. Nurses scored presence of 'worry' and/or dutch-early-nurse-worry-indicator-score indicators every shift or when worried. Vital signs were measured according to the prevailing protocol. Unplanned intensive care/high dependency unit admission or unexpected mortality was the composite endpoint. Percentages of 'worry' and dutch-early-nurse-worry-indicator-score indicators were calculated at various Early Warning Score levels in control and event groups. Entering all dutch-early-nurse-worry-indicator-score indicators in a multiple logistic regression analysis, we calculated a weighted score and calculated sensitivity, specificity, positive predicted value and negative predicted value for each possible total score.
  
  
  RESULTS
  In 3522 patients, 102 (2·9%) had an unplanned intensive care/high dependency unit admissions (n = 97) or unexpected mortality (n = 5). Patients with such events and only slightly changed vital signs had significantly higher percentages of 'worry' and dutch-early-nurse-worry-indicator-score indicators expressed than patients in the control group. Increasing number of dutch-early-nurse-worry-indicator-score indicators showed higher positive predictive values.
  
  
  CONCLUSIONS
  Dutch-early-nurse-worry-indicator-score indicators alert in an early stage of deterioration, before reaching the trigger threshold to call a rapid response team and can improve interdisciplinary communication on surgical wards during regular rounds, and when calling for assistance.
  
  
  CONCLUSIONS
  Dutch-early-nurse-worry-indicator-score structures communication and recording of signs known to be associated with a decline in a patient's condition and can empower nurses to call assistance on the 'worry' criterion in an early stage of deterioration.
authors.affiliation: Care Division, Gelderse Vallei Hospital, Ede, The Netherlands.|Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands.
authors.forename: Gooske
authors.initials: G
authors.lastname: Douw
authors.affiliation: Nursing Science, Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands.
authors.forename: Getty
authors.initials: G
authors.lastname: Huisman-de Waal
authors.affiliation: Care Division, Gelderse Vallei Hospital, Ede, The Netherlands.
authors.forename: Arthur R H
authors.initials: ARH
authors.lastname: van Zanten
authors.affiliation: Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: Johannes G
authors.initials: JG
authors.lastname: van der Hoeven
authors.affiliation: Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands.|Faculty of Health Sciences, Level A (MP11) South Academic Block, Southampton General Hospital, University of Southampton, Southampton, UK.|National Institute for Health Research Collaboration for Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK.
authors.forename: Lisette
authors.initials: L
authors.lastname: Schoonhoven
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000523:psychology*; D002983:Clinical Competence; D015331:Cohort Studies; D003422:Critical Care / Q000706:statistics & numerical data; D018450:Disease Progression; D005260:Female; D057209:Hospital Rapid Response Team; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital / Q000523:psychology*; D012680:Sensitivity and Specificity; D063189:Symptom Assessment; D055986:Vital Signs / Q000502:physiology*; D055815:Young Adult
keywords: deterioration; dutch-early-nurse-worry-indicator-score; hospital rapid response team; intensive care unit; nurses; worry