Association Between Nurses’ Compliance With Adult Early Warning Score Implementation and Inpatient Survival: A Cross-Sectional Study
DOI:
https://doi.org/10.55018/janh.v8i1.595Keywords:
Early Warning Score, Inpatients, Mortality, Nursing Assessment, Patient ComplianceAbstract
Background: The adult Early Warning Score (EWS) is an essential instrument for early detection of a patient's deteriorating clinical condition. However, the effectiveness of EWS depends on nurses' compliance with its implementation. Non-compliance with EWS implementation can hinder early detection of patients' conditions and affect patient survival. This study aims to analyze the relationship between adult EWS implementation compliance and inpatient survival status. However, the evidence on the effect of compliance with EWS implementation on patient survival in real inpatient settings remains limited. This study aimed to examine the association between nurses’ compliance with adult EWS implementation and inpatient survival status.
Methods: This study used an observational, cross-sectional design and was reported according to the STROBE guidelines. The research sample comprised 188 patients selected using a phased sampling technique (cluster sampling followed by simple random sampling). Data were obtained from the medical records of inpatients who met the inclusion and exclusion criteria. The independent variable in this study was compliance with the Early Warning System (EWS), while the dependent variable was the patient's survival status. Statistical analysis was carried out using Fisher's Exact test.
Results: A total of 188 patients were analyzed, with 173 patients (92%) surviving and 15 patients (8%) dying. In the group that did not comply with the Early Warning System (EWS), there were 6 deaths (16.7%) and 30 patients survived (83.3%), while in the group that did comply with the Early Warning System (EWS), there were 9 deaths (5.9%) and 143 patients survived (94.1%). There was a significant association between EWS compliance and inpatient survival status (p = 0.044). Patients with EWS adherence had a higher chance of survival than non-compliant patients (OR = 3.18; 95% CI: 1.06–9.54).
Conclusion: The implementation of EWS that is compliant plays an essential role in detecting early deterioration of patient conditions and improving patient survival and safety.
Downloads
References
Albutt, A., Roland, D., Lawton, R., Conner, M., & Hara, J. O. (2022). Capturing Parents ’ Perspectives of Child Wellness to Support Identification of Acutely Unwell Children in the Emergency Department. Journal Patient Safety, 18(5), 410–414. https://doi.org/: 10.1097/PTS.0000000000000949
Badr, M. N., Khalil, N. S., & Mukhtar, A. M. (2021). Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest , Unplanned ICU Admission , Emergency Surgery , Effect of National Early Warning Scoring System Implementation on Cardiopulmonary Arrest , Unplanned ICU Admission , E. Journal of Multidisciplinary Healthcare ISSN:, 14, 1431–1442. https://doi.org/10.2147/JMDH.S312395
Balshi, A. N., Al-odat, M. A., Alharthy, A. M., Altamimi, M., Th, W., & Id, A. (2022). Tele-Rapid Response Team ( Tele-RRT ): The effect of implementing patient safety network system on outcomes of medical patients – A before and after cohort study. PLoS ONE, 17(11), 1–11. https://doi.org/10.1371/journal.pone.0277992
Bassin, L., Raubenheimer, J., Bell, D., Smith, G. B., Redfern, O. C., Maruotti, A., Recio-saucedo, A., Engvig, A., Wyller, T. B., Skovlund, E., Vali, M., Trygve, A., Hall, S., Rockwood, K., Mette, A., Bjørn, N., Neerland, E., Matino, E., Tavella, E., … Bunkenborg, G. (2020). Nurses ’ Experiences and Perceptions of two Early Warning Score systems to Identify Patient Deterioration — A Focus Group Study. Resuscitation, 39(August 2020), 3548–3562. https://doi.org/10.1016/j.resuscitation.2020.10.037
Briscoe, C. D., Rutare, S., Mccall, N., Monuteaux, M. C., Unyuzumutima, J., Uwamaliya, A., & Id, J. H. (2022). The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting. PLoS ONE, 17(6), 1–15. https://doi.org/10.1371/journal.pone.0270253
Burke, C., & Conway, V. (2023). Factors that influence hospital nurses ’ escalation of patient care in response to their early warning score : A qualitative evidence synthesis. Journal of Clinical Nursing, September 2021, 1885–1934. https://doi.org/10.1111/jocn.16233
Castro-portillo, E., López-izquierdo, R., Castellanos, I. B., Villamor, M. Á. C., Sanz-garcía, A., & Martín-rodríguez, F. (2025). Prehospital Performance of Five Early Warning Scores to Predict Long-Term Mortality in Patients with Suspected Respiratory Infections. Diagnostics, 15(June), 1–15. https://doi.org/10.3390/diagnostics15121565
Cruz-bello, P. (2023). Modified Early Warning Score : Clinical Deterioration of Mexican Patients Hospitalized with COVID-19 and Chronic. Healthcare, 11(September), 1–10.
David, M. C. B., Kolanko, M., Giovane, M. Del, Lai, H., True, J., Beal, E., Li, L. M., & Nilforooshan, R. (2023). Remote Monitoring of Physiology in People Living With Dementia : An Observational Cohort Study Corresponding Author : JMIR Aging, 6, 1–14. https://doi.org/10.2196/43777
Durantez-fernández, C., Martín-conty, J. L., Medina-lozano, E., Mohedano-moriano, A., Polonio-lópez, B., Maestre-miquel, C., Viñuela, A., López-izquierdo, R., Sánchez, R., & Martín-rodríguez, F. (2021). Intensive & Critical Care Nursing Early detection of intensive care needs and mortality risk by use of five early warning scores in patients with traumatic injuries : An observational study. Intensive & Critical Nursing, 67(May), 1–8. https://doi.org/10.1016/j.iccn.2021.103095
Eddahchouri, Y., Koeneman, M., Plokker, M., Brouwer, E., Belt, T. H. Van De, Goor, H. Van, & Jh, S. (2021). International Journal of Nursing Studies Low compliance to a vital sign safety protocol on general hospital wards : A retrospective cohort study. International Journal of Nursing Studies, 115, 103849. https://doi.org/10.1016/j.ijnurstu.2020.103849
Ede, J., Jeffs, E., Vollam, S., & Watkinson, P. (2020). A qualitative exploration of escalation of care in the acute ward setting. Nursing in Critical Care, 25(September 2019), 171–178. https://doi.org/10.1111/nicc.12479
Ede, J., Pickworth, H., Kent, B., Watkinson, P., & Endacott, R. (2025). Intensive & Critical Care Nursing A retrospective records review comparing the care of patients who either avoided or were admitted to an ICU following a ward-based deterioration event. Intensive & Critical Care Nursing, 90(June), 104064. https://doi.org/10.1016/j.iccn.2025.104064
Flenady, T., Dwyer, T., Sobolewska, A., Lagadec, D. Le, Connor, J., Kahl, J., Signal, T., & Browne, M. (2020). Developing a sociocultural framework of compliance : an exploration of factors related to the use of early warning systems among acute care clinicians. BMC Health Services Research, 20(6), 1–9. https://doi.org/ 10.1186/s12913-020-05615-6
Hao, A., Fang, S., Lim, W. T., & Balakrishnan, T. (2020). Early warning score validation methodologies and performance metrics : a systematic review. BMC Medical Informatics and Decision Making, 8(20), 1–7. https://doi.org/10.1186/s12911-020-01144-8
Hwang, J., & Chin, H. J. (2020). Relationships between the National Early Warning Score 2 , clinical worry and patient outcome at discharge : Retrospective observational study. Journal of Clinical Nursing, 29(February), 3774–3789. https://doi.org/10.1111/jocn.15408
Hwang, J., & Kim, S. W. (2022). Using an Early Warning Score for Nurse Shift Patient Handover : Before-and-after Study. Asian Nursing Research, 16(1), 18–24. https://doi.org/10.1016/j.anr.2021.12.005
Ismail, S., Wardah, Z., Wibowo, A., Pranata, S., & Wahyuni, S. (2025). Predictive Analysis of Clinical Status Assessment of Critical Patients Using Electronic Early Warning System Records with Machine Learning. The Malaysian Journal of Nursing, 17(July), 21–29. https://doi.org/10.31674/mjn.2025.v17i01.003
Jayasundera, R., Neilly, M., & Smith, T. O. (2018). Are Early Warning Scores Useful Predictors for Mortality and Morbidity in Hospitalised Acutely Unwell Older Patients ? A Systematic Review. Journal of Clinical Medicine, 7(309), 5–8. https://doi.org/10.3390/jcm7100309
Jeppestol, K., & Kirkevold, M. (2022). Assessing acute functional decline in older patients in home nursing care settings using the Modified Early Warning Score : A qualitative study of nurses ’ and general practitioners ’ experiences. International Jounal of Older People Nursing, 17(August 2021), 1–11. https://doi.org/10.1111/opn.12416
Langkjaer, C. S., Bove, D. G., Nielsen, P. B., Iversen, K. K., Bestle, M. H., & Bunkenborg, G. (2021). Nurses ’ Experiences and Perceptions of two Early Warning Score systems to Identify Patient Deterioration — A Focus Group Study. Nursing Open, 29(August 2020), 1788–1796. https://doi.org/10.1002/nop2.821
Langkjaer, C. S., Bundgaard, K., Bunkenborg, G., Nielsen, P. B., Iversen, K. K., Bestle, M. H., & Bove, D. G. (2023). How nurses use National Early Warning Score and Individual Early Warning Score to support their patient risk assessment practice : A fieldwork study. Journal of Advanced Nursing, 79(July 2022), 789–797. https://doi.org/10.1111/jan.15547
Markey, S., Chadwick, L., Dowd, E. O., & Doherty, E. M. (2025). Human Factors in Healthcare Why do escalation pathways fail ? A human factors perspective on early warning systems in acute Irish hospitals. Human Factors in Healthcare, 8(May), 100117. https://doi.org/10.1016/j.hfh.2025.100117
Martín-, F., Sanz-, A., Laura, G., Guijarro, M., Ortega, G. J., Gómez-, M., Pérez, E., Castro, M. A., Santos, J. C., Juan, P., & Benito, F. D. (2021). adjusted NEWS predicts mortality in suspected patients with COVID- 19 from nursing homes : Multicentre retrospective cohort study. JAN, 20(March), 1–14. https://doi.org/10.1111/jan.15039
Mourik, N. Van, Oomen, J. J., Vught, L. A. Van, Biemond, B. J., Bergh, W. M. Van Den, Blijlevens, N. M. A., Vlaar, A. P. J., & Müller, M. C. A. (2023). Intensive & Critical Care Nursing The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy – A multicenter observational study. Intensive & Critical Care Nursing, 79(June), 103486. https://doi.org/10.1016/j.iccn.2023.103486
Nagarajah, S., Krzyzanowska, M. K., & Murphy, T. (2022). Early Warning Scores and Their Application in the Inpatient Oncology Settings. JCO Oncology Practice, 18(6), 465–474. https://doi.org/10.1200/OP.21.00532
Nima, S., Langsted, D., Jacob, J., Yde, J., Kristine, M., & Mackenhauer, J. (2019). How comorbidities impact Early Warning Score as a predictor of 7-day mortality. Wolters Kluwer Health, 30(September), 1–5. https://doi.org/10.1097/MEJ.0000000000000633
Oanesa, R. D., Su, T. W., Weissman, A., Denise, R., Su, T. W., Weissman, A., Denise, R., Su, T. W., & Weissman, A. (2024). Evidence for Use of Validated Sepsis Screening Tools in the Prehospital Population : A Scoping Review Evidence for Use of Validated Sepsis Screening Tools in the Prehospital Population : A Scoping Review. Prehospital Emergency Care, 28(3), 485–493. https://doi.org/10.1080/10903127.2023.2224862
Park, D., So, K., Kumar, S., Chulho, P., Lee, J. J., & Sohn, J. (2025). Early warning score and feasible complementary approach using artificial intelligence-based bio-signal monitoring system : a review. Biomedical Engineering Letters, 15(June), 717–734. https://doi.org/10.1007/s13534-025-00486-4
Smith, J., Filmalter, C., Masenge, A., & Heyns, T. (2022). African Journal of Emergency Medicine The accuracy of nurse-led triage of adult patients in the emergency centre of urban private hospitals. African Journal of Emergency Medicine, 12(2), 112–116. https://doi.org/10.1016/j.afjem.2022.02.007
Spångfors, M., Molt, M., & Samuelson, K. (2020). National Early Warning Score : A survey of registered nurses ’ perceptions , experiences and barriers. Journal of Clinical Nursing, 29(December), 1187–1194. https://doi.org/10.1111/jocn.15167
Tomas, E., Escoval, A., & Antunes, M. L. (2024). African Journal of Emergency Medicine Cross-cultural adaptation of National Early Warning Score 2 to Angolan Portuguese. African Journal of Emergency Medicine, 14(January), 145–149. https://doi.org/10.1016/j.afjem.2024.06.006
Ulica, E., Alves, C., Pascoal, C., Tom, E., Escoval, A., & Lina, M. (2026). African Journal of Emergency Medicine Effectiveness of early warning scores in predicting in-hospital mortality and adverse events in adult general-ward patients in low- and middle-income countries : A systematic review. African Journal of Emergency Medicine, 16(December 2025), 1–8. https://doi.org/10.1016/j.afjem.2026.100943
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Novia Faizatiwahida, Viky Noviani Hemu, Rondhianto Rondhianto, Baskoro Setioputro, Rismawan Adi Yunanto, Ruris Haristiani, Superzeki Zaidatul Fadilah

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.














