The present study shows that MEWS helped RNs in home care to concretise patient information, which could support their clinical reasoning and decision-making when vague and diffuse symptoms occur in elderly home care patients. RNs and GPs both thought MEWS was successfully implemented as an important shared interdisciplinary tool to assure comprehensive clinical assessment and communication of vital parameters. However, they also experienced difficulties in using MEWS with the elderly patient group and in complying with MEWS trigger recommendations and when to contact the medical service. In the following the findings are described in further detail.
Strengths of MEWS as a supportive clinical decision-making-tool
Assessing vital parameters is central to clinical reasoning and decision-making for health care personnel working with patients in unstable clinical conditions. The interviews with the RNs and GPs showed that MEWS had become an important tool in facilitating their clinical reasoning and decision-making when acute functional decline was detected in home care. MEWS was used as a support, along with several comprehensive assessments and considerations in home care. The following section presents the strengths identified by RNs and GPs related to using MEWS as a support in clinical reasoning and decision-making in home care.
Concretisation of vague and diffuse symptoms of acute illness
The RNs reported that they used MEWS when they detected newly emerging functional decline and vague, diffuse symptoms deviating from the patient’s habitual condition and daily function. One RN described how she noticed functional decline in a patient:
‘He was quite lucid, but his gait function was reduced. That was kind of how you noticed it’. (RN‑4)
The RN had noticed a slightly change in the patient’s gait function, which made her aware of the possibility of that the functional decline could be caused of acute illness. Another RN described that MEWS was used to concretize vague and diffuse symptoms in order to reason if the patient's condition objectively had deteriorated:
‘I guess it’s like…when you see the care recipient, and he doesn’t behave like he normally does. Either you see that he is clammy or sweaty or that he says: “I’m not….there’s something today...I don’t know what it is, but I’m not like I usually am”. Then we tend to do MEWS’. (RN‑3)
The detection of symptoms and functional decline could be observed and reported by RNs or other health care staff, patients’ relatives or patients themselves. The RNs communicated that they were using their clinical gaze which, in these situations, was a cognitive process that supported RNs in reasoning about the situation and in making decisions about whether patients were in their habitual condition.
The RNs also emphasised the importance of listening to what patients told them about their chief complaint in combination with the clinical gaze, obtaining the medical history and trying to identify the cause of the functional decline. One RN explained that she identified functional decline when patients themselves expressed irregular symptoms:
‘I have experienced it twice at work, where the patients in their habitual state could complain about symptoms like “feeling weak and unwell.” And MEWS showed that both had very low blood pressure! And to be honest, I don’t think we would have detected it otherwise’. (RN‑18)
The concretisation of vague and diffuse clinical symptoms supported this RN’s clinical reasoning, so clinical information could then be reported to the GP. Minor deviations in vital parameters that lead to hypo- or hypertension, or tachycardia or bradycardia, could be detected with MEWS in some cases. Furthermore, more severe deviations like dehydration, infection and sepsis could also be detected. RNs in all municipalities provided examples of cases in which MEWS had helped them detect sepsis. They noted that sepsis develops rapidly in elderly patients and found it difficult to recognise with only the clinical gaze and no objective measurements. Furthermore, RNs were also aware that vital parameters can rapidly deteriorate in elderly patients, and parameters within normal MEWS reference values could be abnormal for an elderly home care patient.
MEWS supported RNs and GPs in their clinical reasoning and decision-making by concretising vague and diffuse symptoms. However, this underlines the importance of using a combination of the objective measurements in MEWS, the clinical gaze and judgement in clinical reasoning and decision-making with this group of patients.
MEWS baseline measurements in support of clinical judgment
The RNs explained that all home care teams in the municipalities under study were intended to have habitual vital parameters documented in all home care patients’ electronic records. Some home care teams routinely conferred with the GP after they had performed MEWS baseline measures to ensure that vital signs, which were often outside the cut-off scores, were considered normal for the individual. Conferring with the GP was especially common for patients with congestive heart failure, chronic obstructive pulmonary disease (COPD) and other chronic disorders that habitually caused vital parameters outside the frame of reference. This practice made RNs more confident in assessing the MEWS scores because it supported their reasoning about causes of acute functional decline:
‘You have to consider what’s causing it if there is a change in a MEWS score’. (RN‑33)
RNs often described performing additional examinations like C-reactive protein tests and urine samples before contacting the GP in order to be proactive and to provide as much information as possible to find the cause of the change in vital parameters. They also checked MEWS scores in patients’ habitual states to assess the severity of physical changes.
Knowing the patients emerged as a common theme in all interviews with both RNs and GPs. The full sense of ‘knowing the patients’ includes detailed knowledge about how they managed daily functional activities and their diagnoses, including MEWS scores and vital parameters in their habitual state. One RN explained that knowing the patient was important to understanding the clinical situation and making proper decisions:
‘A lot of our patients have dementia, and they are often unable to express symptoms; you just really have to know your patients in order to assess if it’s normal or not’. (RN‑3)
The RNs’ knowledge of their patients’ habitual state was important for them to be able to recognise new symptoms and determine whether it was necessary to make further clinical assessments or contact the medical services.
The GPs also noted the importance of RNs’ knowledge of patients’ habitual states when they assessed MEWS scores and symptoms of acute functional decline. This knowledge of the patients appeared to have strengthened the cooperation regarding decision-making about whether to start or defer medical treatment or whether the patient should be admitted to hospital.
The RNs also highlighted the importance of providing ‘additional information’ when acute functional decline occurred. MEWS scores and parameters in both the habitual state and acute situation were important, but additional information was needed to assess the severity of a patient’s condition; thus, objective measurements alone could not support health care personnel in clinical reasoning and decision-making processes.
Improvement of interdisciplinary clinical communication
GPs and RNs cooperate to give patients in home care appropriate medical treatment. The main form of communication between RNs and GPs is telephone or electronic messages. In order to promote efficiency and quality in this work, both GPs and RNs emphasised the importance of concise and clear communication and noted that MEWS facilitated that.
One GP reported that he received more specific referrals and more complete and objective information from the RNs after MEWS was implemented:
‘A lot of the work is already done when we communicate with the nurses now. Before MEWS, there were a lot of telephone calls and pulses were not taken, or the respiratory rate…so this has eased our job when we assess by telephone. It has especially eased my workday’. (GP‑36)
The quality of information made GP’s decisions more effective and GPs could assess inquires by telephone or electronic messages. This expanded the GP’s ability to treat patients in general as they had less need to visit the patients in the home. Another GP points out that RNs presented more relevant information after MEWS was implemented:
‘Really, before MEWS... I could ask the nurse…what is the respiratory rate? It really didn´t happen. It didn´t happen before…or…I didn´t get the answer to these questions. It´s something that has happened after implementing MEWS. I don´t think the nurses took the respiratory rate. They would say, “shortness of breath” or “no shortness of breath” or “the patient is breathing fast”’. (GP‑3)
According to both GPs, and RNs, MEWS has given the RNs an increased awareness of the need to perform vital measurements and communicate both objective and subjective data. The improved accuracy in medical communication between GPs and RNs appeals to the GPs and creates a more equal role in the collaboration, which also made the GPs work more efficiently. The RNs also reported that their observational skills had improved and that they now assessed all parameters more comprehensively than they had before MEWS was implemented.
One GP had the impression that interdisciplinary cooperation had become more proactive after the introduction of MEWS, which could prevent unnecessary adverse events:
‘I think it is easier now to make assessments early in the process. It has changed the course of treatment for the patients. We can initiate medical help early, or we can say no, it's safe to wait. You might avoid unnecessary hospital admissions, for example’. (GP‑14)
The implementation of MEWS had improved health personnel’s ability to carry out appropriate medical reasoning and make better decisions for patients. MEWS supported interdisciplinary communication in clinical reasoning and decision-making, which in turn led to a general improvement of clinical practice, according to both RNs and GPs.
Limitations of MEWS in non-institutional care settings
MEWS has become an important clinical decision-making tool in home care, and, as detailed above, its implementation improved collaboration between RNs and GPs in their clinical practice. However, implementing MEWS, which was developed for use in hospital settings, in a non-institutional care setting, entails clinical and contextual challenges. In the following section, we present the experiences of RN and GPs regarding the limitations of using MEWS to assess elderly patients with acute functional decline in home care.
Adjustments of MEWS reference values to fit the patient group
The RNs and GPs emphasised that geriatric patients had many chronic diseases that often cause diffuse and vague symptoms and deviations from habitual state vital parameters. The lack of non-adjusted reference values in the MEWS with geriatric patients was clearly identified as a limitation by an RN:
'We work a lot with geriatric patients, and I think that MEWS is not adapted to geriatric patients. It’s kind of like it would be suitable for me if I’m hospitalised’. (RN‑4)
RNs found that they rarely could relate to the normal MEWS reference values because elderly patients’ reference values – even in their habitual state – often deviated from those values. RNs constantly had to assess and differentiate between normal or abnormal vital parameters by disregarding the normal MEWS reference values.
In particular, RNs and GPs in all municipalities identified a challenge with reference values for the respiratory rate. One RN emphasised that most patients had a higher respiratory rate than MEWS reference values indicated as normal:
‘I think that the respiratory rate score is very low; it’s for a healthy person, and we really have none of those’. (RN‑2)
The RNs could not trust the MEWS reference values of respiratory rate, and resulted in uncertainty and ambiguity rather than support in clinical reasoning and decision-making. Another RN further emphasized that she was often in fear of making incorrect decisions when assessing a patient whom she did not know or could not physically see:
‘We are very often asked to assess MEWS scores performed by skilled workers, and let’s say they report a score of 1 because of elevated respiratory rate….Well, I sometimes fear that I overlook a MEWS score that I should really react to’. (RN‑4)
The MEWS reference values of normal respiratory rate could, according to the RNs, lead to a lack of responsiveness on their part; some even feared that they would not detect and react to early signs of clinical deterioration because their experience had taught them that the majority of elderly patients had a respiratory rate above 14, which is considered abnormal according to MEWS. The reference values for blood pressure were also cited as too broad; the same was true of the reference values for temperature, which in elderly persons can be falsely low due to medication use. The normal MEWS reference values for temperature can camouflage fever and a delayed physiological response in geriatric patients. The health care personnel were obliged to carry out comprehensive clinical reasoning and make decisions while interpreting measurements with a tool that was perceived as not suited to the patient group in particular.
In home care, RNs have the greatest responsibility for all patients. A dilemma could arise if other workers – skilled or unskilled – needed more competence to interpret a MEWS score when patients had symptoms of acute functional decline. This clinical dilemma would escalate if an RN did not know the patient or could not prioritise seeing the patient. In these situations, MEWS did not support health care personnel in their clinical reasoning or decision-making, because the reference values were not sufficiently tailored to the elderly in home care. The non-adjusted reference values were highlighted by RNs in all interviews as a significant limitation that could lead to uncertainty in the clinical reasoning and decision-making processes.
Adjustment of MEWS trigger recommendations to the home care setting
The MEWS trigger recommendations were described by RNs as challenging to comply with in the home care context. Unlike a hospital setting, home care nurses do not see their patients around the clock; nor do they have immediate access to medical services in the event of acute illness.
RNs indicated that it was not always feasible to follow the MEWS trigger recommendations in home care because of geographical distance and work lists with limited flexibility. One RN described the great distances involved in the southern Norway home care context and how it becomes impractical to comply with MEWS trigger recommendations:
‘To achieve continuity all the time…it’s fine if they live close to the base, but if the patient lives far away, for example, a 40-minute drive, and you are supposed to perform a MEWS again 2 hours later’. (RN‑2)
RNs made decisions regarding how and when to follow up after taking a MEWS measurement based on their clinical reasoning, often by consulting other colleagues and, if possible, by consulting with other health professionals for an interdisciplinary assessment. Another RN explained that, although the MEWS trigger recommendations were not routinely followed, comprehensive reasoning was safely adjusted to each patient’s situation:
‘It should be said that we are not that structured when it comes to the follow-up intervals. But sure, we do our own reasoning, even if it’s a score of 3 or 2’. (RN‑44)
RNs in home care were forced to make decisions that were in line with MEWS trigger recommendations. However, another RN found that the colour codes organised the assessments and that follow-up intervals were actually systematised:
‘But what I think is OK with the colour codes in the MEWS card is that it tells me if it’s a yellow score, the patient should be followed up in a certain period of time. If it’s a score of 4, we contact a physician. We can sometimes wonder whether we should contact the physician, but when it’s a score of 4, we do contact the physician’. (RN‑26)
The RN used colour codes to visualise the severity of each patient’s health condition and found that MEWS provided concrete guidelines in clinical reasoning and decision-making.
According to several RNs and GPs, a MEWS score of 0 was easy to assess, because they considered the clinical situation to be stable and normal, but they were aware of the prospect of making incorrect decisions. One RN described the constant possibility of making the wrong decision by relying solely on objective parameters:
‘There is a risk of blindly trusting the measurements and not interpreting the clinical situation. [MEWS] is a starting point, but there can be serious misjudgements'. (RN‑44)
A MEWS score of 1–3 also resulted in a dilemma for further clinical reasoning and decision-making, especially if the health care provider did not know the patient or have access to electronic patient records with the habitual vital parameters. A MEWS score higher than 3 or the presence of clinical indications for acute illness were situations that RNs and GPs found easy to assess because they reasoned the situation to be severe. If RNs considered the situation to be unstable and new MEWS measurements had to be done beyond the planned work, priority was given to new measurements, and they organised doing the follow-ups. They also considered other factors, such as whether the patient lived alone, the patient’s distance from the home care base and whether it was close to a weekend, when the GP office was likely to be closed for several days during the reasoning and decision-making process. If the MEWS score or the patient’s clinical condition indicated frequent measurements because of an unstable health condition or if the patient had deteriorated significantly, the RNs often reasoned that it was not prudent to keep them at home. These situations often led RNs to contact the GP or the after-hours emergency service, and the patient was often admitted to a higher level of care, such as a nursing home, the municipal emergency care unit or the hospital. MEWS trigger recommendations did not appear as a support for RNs in clinical reasoning and decision-making.
Both strengths and limitations of using MEWS emerged from the experiences of RNs and GPs in home care. Although MEWS supported health care personnel in many clinical situations, the unadjusted reference values and trigger recommendations in MEWS indicated that a EWS tool designed for hospital practice, like MEWS, cannot and should not be easily transferred to community care settings without adjustments.