Management of abnormal observations in the emergency department: A review

Abstract

Objective To assess utility and accuracy of general observation modified early warning score charts; and compare sensitivity and specificity of single‐ and multiple‐parameter‐based trigger scores on patient outcomes in the ED.

Methods Retrospective cohort clinical audit of all adult Modified Early Warning Score charts in the ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate Modified Early Warning Score and evidence of response.

Results Of 5901 ED presentations, medical records system identified 2482 Modified Early Warning Score; 347 were missing or blank. Of 2135 Modified Early Warning Score charts, 19.5% contained a calculation error, 51.9% had one or more missing parameters and 36.6% did not have usual/target systolic blood pressure recorded; with 25.1% (95% confidence interval [CI] 23.3–27.0) charts correctly completed. Four hundred and forty‐three had a single‐abnormal parameter of which chart review showed 96.6% (94.5–97.3) were identified as abnormal by nurses with 25.7% (21.9–30.0); only 5.6% (3.9–8.2) had evidence of recognition by medical staff. Modified Early Warning Score sensitivity and specificity for ward admission was 14.7% and 96.1%, respectively. Modelling using the dataset of a single‐abnormal parameter suggested sensitivity and specificity of 31.6% and 85.8%, respectively.

Conclusions This study highlights serious deficiencies in documentation of abnormal parameters and emergency response. It has also shown poor accuracy of both single‐ and multiple‐parameter‐based trigger scores in predicting patient outcomes within the ED. However, single‐parameter‐based trigger scores are twice as sensitive as total Modified Early Warning Score for admission and reduces documentation error by 23%.