• Gooske Douw, Getty Huisman-de Waal, van Zanten Arthur R H ARH Medical Advisor Executive Team, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands. Electronic address: ZantenA@zgv.nl., Johannes G van der Hoeven, and Lisette Schoonhoven.
• Gelderse Vallei Hospital, Care Division, Ede, The Netherlands; Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21 (route 114), 6525 EZ Nijmegen, The Netherlands. Electronic address: douwg@zgv.nl.
• Int J Nurs Stud. 2018 Sep 1; 85: 90-95.

BackgroundRapid response systems aim to improve early recognition and treatment of deteriorating general ward patients. Sole reliance on deviating vital signs to escalate care in rapid response systems disregards nurses' judgments about a patient's condition based on worry and other indicators of deterioration. To make worry explicit, the Dutch-Early-Nurse-Worry-Indicator-Score was developed, summarising non-quantifiable signs of deterioration in the nine indicators: breathing, circulation, temperature, mentation, agitation, pain, unexpected trajectory, patient indicates not feeling well and nurses' subjective observations. Nurses' worry can be present even when vital signs are largely unchanged, enabling treatment to commence at an early stage. On the other hand, reliance on nurses' worry might lead to unnecessary calls for medical assistance or an overuse of rapid response teams.ObjectivesExplore the occurrence of nurses' worry in real time, determine whether acting on worry leads to unnecessary action and determine the indicators present at different levels of deterioration.DesignA prospective cohort study.SettingThree surgical wards in a tertiary, university affiliated teaching hospital.ParticipantsAll nurses participated and adult, surgical, native speaking patients were included in the study.MethodsA descriptive analysis is performed on one year of data on surgical ward nurses' experience of worry and its underlying indicators in addition to routinely measured vital signs.ResultsOut of a total of 46,571 measurements, vital signs were normal 18,727 times, with worry expressed 605 times (3%), resulting in 62 calls (10.2%) to the attending physician. More than half of these calls resulted in necessary interventions. Calls for assistance and subsequent intervention after worry was expressed increase in parallel with early warning scores. The breathing indicator showed the highest increase in frequency with increasing deviation in vital signs.ConclusionThis study suggests that worry has potential as an early indicator of deterioration, alerting nurses and encouraging them to start timely interventions. Overuse of medical assistance could not be determined, The Dutch-Early-Nurse-Worry-Indicator-Score objectifies worry when vital signs do not support its presence and systematic assessment of these indicators is recommended.Copyright © 2018 Elsevier Ltd. All rights reserved.

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