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Chapter I Problem and Its Background


Theoretical Framework

Conceptual Framework

Statement of the Problem


Scope and Delimitation

Significance of the Study

Definition of Terms

Chapter II Review of Related Literature


Chapter III Research Methodology

Research Design


Population Frame


Sampling Technique




Research Instrumentation


Data Gathering Procedure


Data Analysis and Treatment


Ethical Consideration




Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Chapter I
General adult patients in hospitals can have unexpected physiological
deterioration that if left unrecognized, can lead to critical illness, intensive care
unit (ICU) admission, cardiac arrest and/or death. Early identification of the
sickest patients may allow earlier intervention, thus potentially improving their
outcome. This problem was the subject of numerous critical care studies and
since there are very limited local studies regarding the same topic, the
researchers have decided to pave the way in exploring this topic.
As there is an upsurge of critically ill patients, the interest in formulating
strategies for detecting at-risk patients also increases. Resuscitation Council
(2010) added that regular monitoring and effective treatment of seriously ill
patients appear to improve clinical outcomes, thus the basis for monitoring
patients vital signs. Abnormal physiology is common in adult care wards, yet the
important physiological observations of patients are considered and recorded
less frequently than is desirable.
Scoring systems have been developed in answer to an increased
importance on the evaluation and monitoring of health services. These systems
enable comparative and evaluative research of intensive care. (M. Rao, 2008)
One of the most reliable tools used in scoring is the Early Warning System
(EWS) tool, which was introduced by the American Department of Health (2000)

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

as part of the recommendations in the comprehensive critical care report. The

EWS, also known as track-and trigger systems, is the calculation of the
combined generated score based on physiological abnormalities of heart rate,
blood pressure, respiratory rate, temperature, urine output and level of
consciousness. It is intended to support objective decision making to help staff
identify deteriorating patients.
There are more than 5 million patients who are considered critically ill in
the United States with an average mortality rate of 10-29%. These patients
diseases range from multi-organ failure, cardio vascular failure and sepsis, which
can further lead to renal failure, acute respiratory failure and the like. (Society of
Critical Care Medicine, 2015). In the Philippines, there is one study that was
conducted in a tertiary hospital in Cebu City where they utilized the Pediatric
Early Warning Scoring (PEWS) and Banque et.al (2009) stated that there is a
significant relationship between PEWS and clinical deterioration correlated with
PICU/ICU set-up admission thus, they concluded that it is a simple and reliable
scoring system that will aid in identifying pediatric patients at risk for clinical
In San Juan de Dios Educational Foundation Inc. (Hospital) the Early
Warning System has not been introduced, but the parameters used by EWS can
easily be supported by the physical set of SJDEFI. Then, as part of continual
development of quality care and patient safety in our institution, the researchers
is aiming to introduce the tool

to evaluate the impact of utilizing the Early

Warning System Tool in detecting physiologically deteriorating patients in a unit

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

of the adult care section of San Juan de Dios Educational Foundation, Inc.

Theoretical Framework
The Helping Art of Clinical Nursing was produced by Ernestine
Wiedenbach. It characterized nursing as the act of recognizing a patient's need
for help through proper recognition of symptoms and behaviour, recognizing the
cause of the distress, recognizing whether the patient has a need of assistance
from the nurse or the health care team. Being able to identify the degree of the
need for help of each patient allows nurses to provide holistic care. Prevention of
complications and promotion of comfort are the nursing goals of the theory.
(Weidenbachs Helping Art of Clinical Nursing, 2013).
Wiedenbach elaborates that clinical judgement of the nurses based on
actual existence and based on the analysis the causes and effects can lead to
good decision-making. Sound judgement is the capacity to assess situations or
circumstances clearly and to draw sound conclusions that enhances through
time, that increases the clarity of professional purpose. In this theory, nursing
skills are done to accomplish a patient-focused purpose instead of the fulfilment
of the skill itself being the finished objective. Skills are composed of different
activities that are defined as the unity of action, accuracy and the productive use
of self.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Conceptual Framework
The studys main purpose is to appraise the impact of utilizing the Early
Warning System Tool in assessing physiological deterioration in a unit of the
adult care section of San Juan de Dios Educational Foundation, Inc. (Hospital).
The first receptacle encompasses the demographic data of the respondents.
The second receptacle represents the Early Warning System tool. The connector
between the first and second receptacle is the utilization of the tool, which will
yield the output of the study: the impacts of utilizing the Early Warning System
tool. The connector between the first and third receptacle signifies the
relationship between the demographic data of respondents and impact of using
the EWS tool.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)


This study aims to determine the impact of utilizing the Early Warning System
tool in a unit of the San Juan de Dios Educational Foundation, Inc.
This study specifically aims to answer the following questions:
1. What are the demographic data of the respondents in terms of:
a. age
b. gender
c. length of experience
2. What are the impacts of utilizing the Early Warning System tool?
3. Is there a significant relationship between the demographic data of the
respondents and the impact of utilizing the Early Warning System Tool?
4. Based on the findings, what recommendations can be made in the use of the
Early Warning System Tool?

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

H1: There is a significant relationship between the demographic data of
the respondents and the impacts of utilizing the Early Warning System tool.
Scope and Delimitation
The descriptive study aims to focus on evaluating the impact of utilizing
the Early Warning Systems (EWS) Tool. This will be used on patients admitted in
the Adult Care Unit (La Milagrosa Unit) of San Juan de Dios Educational
Foundation Inc (Hospital).
An instructional video from the website of Wellington Hospital will be
utilized as a means of orienting the nurses about the Early Warning System
Secondly, it will be implemented on the unit then, nurses from the unit will be
asked to give scores per determinant depending on degree of abnormality of
retrieved data on the EWS tool.One month will be allotted time for the data
gathering and the implementation of the tool in the unit. Lastly, an evaluation tool
will be provided to determine the impact of utilizing the EWS tool as an
assessment tool in determining early signs of deterioration
The population frame will be 25staff nurses of a unit of the adult care
section. All nurses who met the inclusion criteria will be invited to be the
participants of the study. The regulation parameters are as follows: (1) Nurses
under probationary and regular employment, (2) Nurses of both gender and of
any age will be included in the study, and (3) nurses assigned in La Milagrosa

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Unit. One month will be allotted time for the data gathering. The EWS tool will be
used only for assessment and will not recommend any specific intervention.


This study will be designed to evaluate the Impact of utilizing the Early
Warning System Tool.
To the Patients. The Early Warning System tool can be used to monitor a
patients progress and provide specific criteria according to their score that will
recognize early deterioration. It will also improve and encourage effective
healthcare and patient teamwork and communication thus improving critical
patient outcomes and patient safety.
To the Nurses. This study will enhance the assessment skills of nurses and
improve clinical judgment especially on critically ill patients. This will also
enhance collaboration within health care team.
To the Hospital Institution. This study will propose to enhance the quality of
healthcare service that will increase customer satisfaction.
To the Future Researchers. The result of the study will encourage future
researchers to conduct studies related to this area of interest by providing the
foundation of knowledge in the assessment of the Early Warning Score tool.
Definition of Terms

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

To ensure common understanding between the investigator and the readers,

the following terminologies have been defined:
Patients- all individuals admitted to La Milagrosa Unit
Nurses- Healthcare service provider, whether regularized or under probation
Critically Ill- Patients who are for possible critical care unit transfer, who needs
intensive monitoring, with high dependency
Early Warning System Tool- in this study, the term "checklist" is defined as the
list of things and actions contained in the Early Warning System Tool which
compromises of five (5) determinants: heart rate, systolic blood pessure,
respiratory rate, 4- hour Urine Output, and level of consciousness.
Evaluation Tool- questionnaire to be given to respondents after utilization of
EWS tool for at least 1 month
Length of Experience- number of months or years employed in SJDEFI
Impact- specific effect of the EWS tool utilization to nurses

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Critically Ill patients
Critical illness can be defined as any disease that leads to physiological
instability, where in the patient is at risk of death or disability within a short
amount of time. (British Journal of Hospital Medicine, 2007) According to Society
of Critical Care Medicine, critically ill patients have increased to 5 million in the
United States alone. Multi-organ failure and sepsis were recorded to have
highest occurrence with regard to critical illness and cardiac arrest as the leading
cause of death. Aside from late detection of physiological deterioration, one other
reason for the high rate of critically ill deaths is the late transfers to Intensive
Care Units. This may be because of late recognition of need for transfer or
unavailability of ICU beds. As these findings are presented, the search for
interventions that may lead to better clinical outcomes or prevention of any
untoward effect is also on the rise. (Robertson, Al-Haddad, 2012) Some of the

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

interventions tested in other countries to cope up with the statistics are (1)
creation of outreach teams, which comprises of nurses and doctors trained
specifically in resuscitative management of critically ill patients and (2) creating
Early Warning System tools to aid in identifying at risk patients. (Nursing Times,

Early Warning System

Patients admitted into hospital as a medical emergency are at risk of
deterioration in their clinical condition due to their altered physiological state. The
majority of acute illnesses develop gradually over many hours and are
associated with the early presence of abnormal vital signs in the patient. These
abnormalities reflect failing cardiovascular, respiratory and neurological systems
which are known precursors to a critical event (Gwinutt, 2010).
Any patient in hospital may become acutely unwell. However, the
recognition of acute illness is often delayed and its subsequent management
may be inappropriate. This may result in late referral and avoidable admissions
to critical care, and may lead to unnecessary patient deaths, particularly when
the initial standard of care is suboptimal. (NICE, 2007)
The early warning score is a physiological scoring system that can help to
identify physiological deterioration. The close monitoring of patients physiological
parameters is the cornerstone in the early detection of critical illness. The Early
Warning Scoring System (EWS) was developed with the aim of providing a
scoring system which could be readily used by healthcare team to help identify

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

patients that are at risk for being critically ill and to enhance equity in care that
guarantees early recognition of patients with potential or known to be critical ill
and treat the patients effectively and appropriately. The EWS can be summed up
with six physiological parameters (respiratory rate, heart rate, systolic blood
pressure, temperature, neurological status and oxygen saturations) scored
between 0 - 3 with an total score of three or more triggering the start of the study
of Early Warning Score System (EWS) .

The Early Warning Score should be associated with appropriate

communication between medical and nursing staff. Nurses have played an
important role in preventing adverse events in a patients condition. The early
recognition and correct management of physiological abnormality can improve
patient outcomes by reducing the incidence of Adverse events, making nurses
ability to identify, interpret and act on physiological abnormality a fundamental
factor in preventing occurrences of adverse events. Detection of adverse effect in
physiologic data can require a combination of observational expertise, deduction,
and perception, but there are tools that nurses can use to help such as the Early
Warning System (EWS); however awareness of a persons usual state is the
foundation for recognizing any illness.

Early Warning System (EWS) tool focuses on the collection and

interpretation of objective measurements particularly the basic physciologic
parameters, taking the cues identified by prior research which alert nurses to a

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

potential change in the patients condition (Atkinson, D., 2013)

Hence, the goal of using Early Warning Systee (EWS) is to prevent harm,
reduce in-hospital cardiac arrests and mortality rates, and facilitate appropriate
use of Critical Care resources, through early recognition and treatment of the
deteriorating patient.

Vital Signs (Early Warning System)

Historically the course of prognosis of patients depends on the competent
workforce, because it compensates any system failure that might occur during
stay in the hospital (Tucker and Edmondson, 2003). Despite this, a landmark
study found the expertise, skills and experience required to care for patients
when they become acutely unwell is not always possessed by staff in general
ward environments (McQuillan et al, 1998).This suggests that even without the
occurrence of the system failure, the patient might not get the appropriate or
maximum care they should receive when their condition worsen. Clinical tool
such as the vital signs are often used in monitoring patients. This tool reflects
how the critically ill patients deteriorate and that early intervention will improve
outcome. However, perception of the senior staff nurses about vital signs
measurement may be basic or skill-based task rather than a knowledge-based
one (Boulanger and Toghill, 2009). Vital signs measurement may, therefore, be
delegated to less qualified or inexperienced nursing staff (Hogan, 2006). But
possessing knowledge, skills and the ability to think critically is the key not only to

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

measure vital signs accurately but also to interpret and analyze data in the
context of the patients illness and medical treatment (Garcea et al, 2010).
A helpful tool, Early Warning Signs (EWS) was designed to overcome
deterioration in early recognition of shifting of condition of patients from acute to
critical (Goldhill and McNarry, 2004). The data interpretation from assessments is
vital in identifying the level of care a patient requires, providing treatment and
preventing a patient deteriorating from an untoward event(Wheatley, 2006). In
relation to patient outcomes, an early warning system when combined with rapid
response appears to have the potential to reduce cardiac arrests and unplanned
ICU admissions. In a research by University of York (2015), it has been found
that precision of data recording and the calculation of early warning scores can in
turn impact on the accuracy in detecting a patients deterioration whereas
inaccuracies of data can lead to delays in identifying patients at risk or critically
As patients in hospital today are sicker than in the past, nurses can no
longer rely on the traditional five vital signs to determine clinical changes in their
patients. Nurses must not only know how to measure these vital signs accurately,
they must also know how to interpret and act on them. In addition, they must
incorporate additional vital signs when performing assessments of their patients.
In conclusion, it is highly recommended that nurses should use a tool or
method should be used to ensure that nothing is overlooked that may result in a
missed diagnosis or a delay in treatment.
Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Early Warning System: Age, Gender and Nature of the Disease

The elders are correlated with higher clinical risk but the interrelation
among age and physiological response is complicated. Hence chronological age
is not congruent with the biological age. The team was not convinced to apply
age on the basis of scoring for National Early Warning Score. (National Early
Warning Score, 2012)
However, a study entitled Utility of a Single Early Warning Score in
Patients with Sepsis in the Emegency Department by Corfield, et al (2014)
showed that the median age for 2003 respondents was 72 years old and that
there is no significant difference in age between men and women. Patient
admitted to ICU has a median age of 61 years old and has a high National Early
Warning System NEWS) score than those who are not admitted to Intensive
Care Unit. Within 30 days patient who had a high NEWS score and significantly
older had died. Based on the results of the study, patient aged 50-70 years old
were significantly high risk of dying than those patient aged below fifty years old.
A study entitled In-hospital mortality and morbidity of elderly medical
patients can be predicted at admission by the Modified Early Warning Score: A
prospective study revealed that 1107 patients were admitted which were mostly
older than 64 years old. Garnering a result of lesser chances of transfer or death
that proved Early Warning System to be transparent useful tool in predicting a
worse hospital outcome (Cei, et al 2009)

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

The progression of chronic disease involves periods of remission mixed

with exacerbations and multiple hospitalizations. Yet there is uncertainty of the
time, frequency and duration of the next episode of decompensation as well as
the ultimate prognosis causing doubts about its management. Observable signs
of decline in physiologic vital signs are often seen 6 to 8 hours prior to cardiac
arrests. According to Schein et al. (1990), 84% of patients had been observed of
clinical deterioration or new complaints within 8 hours of cardiopulmonary arrest;
in 70% of patients, deterioration of either respiratory or mental function was
observed during the time. Early Warning System Score for the use of adult
patients is a standardized assessment and also, a communication method to
recognize and avoid patient decline that may reduce patient mortality and length
of stay thus, developing a standardized tool to gauge the patient and
corresponding algorithm or guide of action steps that guarantees delivery of
patient care. In a review of adult response team from 2007 to 2010, it has
revealed a decrease in numbers of code blue as the number of rapid response
team calls increased. Compared with PEWS (Pediatric Early Warning System);
Early Warning System is a more complicated because it incorporated aspects
above and below the normal or acceptable range and an expanded algorithm for
responding to the scores to include reassessment by the direct care of thee
nurse every hour for 4 consecutive hours to ensure patient stability. If the patient
didn't remain stable for 4 consecutive hours, the team considered transferring the
patient to a higher level of care.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Therefore, Clinical deterioration can occur at any stage of a patients

illness; however, there may be certain periods when a patient is vulnerable to
deterioration such as during the onset of illness, during medical interventions and
during recovery. Patients who are at risk of deteriorating may be identified prior to
having serious adverse event by changes in their physiological data. Timely
interpretation and escalation of recognized deterioration is of crucial importance
in minimizing the likelihood of serious and adverse events including cardiac
arrest and death.

Early Warning System in Adult Care Section

Every year, 13 million people, are admitted to acute hospitals in England and
Wales. Inevitably, some of these people will die as a result of their illness.
(National Patient Safety Agency, 2007) In general wards, there is a ratio of one
nurse to more patients wherein nurses cater a large number of patients
compared to intensive care unit. Nurses can be called by patient through buzzer
when they need attention and help. Prioritization is a key component in providing
nursing care in the ward. Dependencies of patients are kept into minimum
especially those who can perform self-care. (Orgtalk, 2013)
In research by Fligelstone, et al. (2005), surgical patients referred in an
intensive care unit (ICU) had significant physiological abnormalities that would
have triggered an Early Warning Score for a mean of 12 hours prior to being
referred to medical staff. Physiological data seem to suggest that deterioration of

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

patients on general wards is predictable on the basis of a structured analysis of

physiological bed-side observations.
A study by Godhill, et al (1999) hypothesized that patients admitted to ICU
are often seriously ill before ICU admission. If patients can be recognized and
treated earlier, it may be possible to decrease mortality and the ICU stay of
survivors. Data suggest that respiratory rate, heart rate and the adequacy of
oxygenation are the most important physiological indicators of a critically ill ward
patient. The level of consciousness and presence of renal failure may also be
important indicators. Abnormal values of selected physiological measurements
may be useful as an objective indication that patients are at risk.
Early Warning Score tool is an important tool that warns physicians and the
healthcare team about the health status of the patient. This will help lessen ICU
transfers. Studies revealed that there is a positive relationship between the
magnitude of changed scores of critical patients and need for admission to ICU.
In relation to this study, patient came from the ward have a high morbidity before
they are admitted to ICU with the EWS score of above 3 points in a 70% of the
population with an average above 5 points. Within 72 hours before admission to
ICU dead patients has a significant increase in their EWS scores. As early as
possible using the EWS can prevent clinical deterioration, there is a direct
relation between the critical score of EWS and increasing morbidity or mortality
(Tavares et al,2008)
Patient admitted in the ICU with the EWS score of greater than six has a
significantly higher mortality and it is the independent predictor of death in ICU.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

The Scoring of the EWS on admission to ICU is the same with the Simplified
Acute Physiology Score III and the Sequential Organ Failure Assessment score
on admission. The result of the study reveals that EWS is a useful tool in
assessing patient in the ICU on a 30 day stay and mortality. (Reini et al, 2012)
Studies also suggest that clinical deterioration of patients on general
hospital wards is often preceded by changes in physiological observations that
are recorded by clinical staff six to 24 hours prior to a serious adverse event
(Kause, 2004). In the study by National Patient Safety Agency (2007), Of the 64
cases of patient deterioration identified in 2005 in acute hospital settings, it was
reported that in 14 cases, no observations were made for a prolonged period
prior to death and changes in vital signs were not detected. While in 30 cases,
despite the recording of vital signs, it was reported that there was no recognition
of clinical deterioration and/or no action taken. And the rest of the cases,
deterioration were recognized and assistance was sought.

Early Warning Score is a simple procedure based on bedside observations

that have been recommended to identify patients at risk on general hospital
wards. This approach classifies critically ill patients by need or level of care
required according to the complexity of acute care on a scale of zero where
needs can be met through a normal ward; to three where a patient requires
advanced respiratory support in ICU); and not based by their geographical
boundaries (DOH, 2000).

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

In conclusion, It is found that by identifying patients who are deteriorating

and by acting early, staff and their organizations can make a real difference. They
can also enhance patient safety by improving systems to resuscitate patients
when they have a cardiac arrest.

Impact of Early Warning System (EWS) on Nurses

A fundamental aspect of practice every clinician must grasp is how to
recognize changes in the condition of their patient and most importantly what
they should do to determine if the patients condition is deteriorating. Without this
fundamental practice being understood by all with clinical responsibilities,
patients may well suffer and even die as a consequence.

The main purpose of early warning score systems is to ensure early

identification and response to the deteriorating patient, and ultimately to improve
patient safety. It is important to evaluate it in a hospital context to identify
changes that might be required to optimize performance. Its significance in early
detection and activation of medical response has prompted health services in
Canada, Australia and the UK to implement early warning score systems.
(Patterson., et al, 2011).

In a study by Green A, et al. (2006), as a primary user of the clinical

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

marker referral tool or Early Warning System (EWS) it is important to explore the
healthcare teams perception, attitudes, and perceived understanding of the
implemented tool to assist in the early identification of unstable patients. Overall,
the responses of the healthcare team were positive to the clinical marker tool or
Early Warning System (EWS), offering clear guidelines for staff to respond to the
patient's clinical condition and contact the medical staff and the ICU liaison team
as appropriate.

Nurses play a central role in implementing an early warning score system

and it is important to capture their voice when evaluating the effectiveness of the
tool. In a study by Cox, A., et al (2015) early warning scoring systems are simple
yet several studies reveal problems such as failure to recognize deteriorating
patients or delayed response to them, which suggest that implementation of this
tool can highlight shortcomings in healthcare delivery.

Studies suggest that problems in delay recognition of deteriorating

patients originated from a lack of standardized tool that provides observation
chart and staff training. (Patterson, et al., 2011) Whereas, other studies suggest
that it is staff- related, wherein nurses lack confidence in calling for help when
they think patients are unwell and therefore are reluctant to activate medical
teams. (Cox., et al, 2015)

The evaluation tool was designed to gauge the nurses experiences of

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

using the Early Warning System with regard to its effect on clinical decisionmaking and helping to identify problems in clinical practice. While it was
considered to enhance the nurses role in clinical decision-making, participants
used it to supplement rather than replace clinical judgment. As experienced
nurses, they know that NEWS has limitations.

In conclusion, Participants found that Early Warning System helped them

identify patients who needed to be monitored more closely and they considered
that it was a useful decision-making tool for newly qualified and student nurses.
They found the tool helpful but in some cases, for example in patients with
hypertension and acute myocardial infarction, they also used their clinical
judgment to activate a medical review and did not rely solely on Early Warning

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

This chapter presents the procedures and processes through which this
study is instituted. This chapter covers the research design, sample, research
instruments, the data gathering procedures and statistical tools applied.
Research Design
This study will assess the impact of utilizing the Early Warning System
(EWS) tool in the practice of nurses in La Milagrosa Unit at San Juan de Dios
Educational Foundation, Inc. (Hospital). It will utilize the quantitative nonexperimental, descriptive correlational research design.
A descriptive research gathers pertinent data that can be used for
statistical conclusion on the target audience through data analysis. Correlational
type of descriptive research design seeks to determine the extent of relationship

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

between variables by determining how changes in one variable relate to

changes in another variable. It discovers how the phenomena under study are

The variables of the study are quantifiable for the reason that the
investigators will utilize a checklist tool, which is the Early Warning System and
an evaluation tool to determine the impact of utilizing the Early Warning System

The Population Frame

The respondents of the study consist of all the staff nurses including those
under probationary status and regular employment assigned in La Milagrosa
Unit. Currently La Milagrosa Unit has 25 staff nurses.
Sampling Technique
The sampling technique that will be utilized in this study is the Purposive
Sampling, which is a non-probability sampling technique. Non-probability
Purposive sampling is a sampling technique where respondents are selected
based on the criteria set by the investigators which on this study are the
following: (1) Nurses under probationary status and regular employment, (2)
Nurses of both gender and of any age will be included in the study, and (3)
nurses assigned in La Milagrosa Unit.


Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

The study shall take place in San Juan De Dios Educational Foundation
Hospital, under the Adult Care Section, specifically, La Milagrosa Unit.

Research Instrumentation
The research instrument that will be utilized in this study is the Early Warning
System Checklist. There are five (5) parameters for the Early Warning System
checklist namely: Respiratory Rate, Systolic Blood Pressure, Heart Rate, 4 Hour
Urine Output, and Level of Consciousness. For each parameter, a score from 0-3
may be given depending how far from the normal range the data gathered is. The
researchers of this study took into consideration in asking for permission of the
author via email correspondence regarding the use of the tool.
The research instrument that will be used as the evaluation tool composes of 17
questions that will determine the impact of utilizing the Early Warning System tool
in the nursing practice.The researchers of this study will again take into
consideration asking for permission from the author via email correspondence
regarding the use of the tool.

Data Gathering Procedure

After garnering the approval of the institutional review board, the
researchers will ask for the approval of the unit manager of the La Milagrosa
Unit. The purpose of the study and other important details will be disclosed and
explanation on how the data gathering will commence.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

A pilot study with 10 respondents will be conducted to assess the

feasibility of the study. A general introduction to the tool will be given to the
nurses of each unit to be utilize, so that there will be uniform understanding of the
study. The Early Warning System tool will be used by all nurses of the La
Milagrosa Unit. The EWS tool will be used on all patients handled by the nurse.
After a month we will conduct an evaluation regarding the impact of utilizing the
EWS tool through a questionnaire.

Conduction of pilot study

Approval from unit managers after explanation of study purpose

and process

General orientation for nurses in units to be utilized in study

including introduction to the Early Warning System tool

Utilization of EWS tool twice per 8-hour shift, per patient

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Collation and organization of EWS tools used

Evaluation of the impact of utilizing the Early Warning System

tool by the nurse

Collation and organization of the evaluation tools

Evaluation of the data gathered

Statistical Treatment
Statistical treatment of data is essential in order to mold the data with the
goal of discovering and making appropriate conclusion from the raw data
In the study, the percentage and frequency distribution, weighted mean,
and Spearmans Rho correlation test are use to interpret and analyze the results
of the study. Statistical software called Statistical Package for Social Sciences
was used to analyze the gathered data.
1. Percentage and Frequency distribution will be used to summarize
respondents profile characteristics.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

2. The general weighted mean will be utilized extensively in descriptive

statistical analysis of data gathered among respondents.
3. Spearman rho correlation test will be utilized to determine the significant
relationship between the profile characteristics of the nurse and the evaluation
tool scores.
Ethical Consideration of Research
The purpose of the study will be discussed to the respondents. Before the
study was conducted, the researchers will assure the respondents that results
will be treated with confidentiality. A letter will be given to the respondents stating
the objectives and purpose of the study.
An informed consent will be secured from the respondents after
explaining the process of the study. Respondents have the right to autonomy,
he/she could decide whether to participate or not at any given time during the
whole study.

Reliability Test: Critical Utilization of Early Warning System (C.U.E.W.S.)

Alasdair R Corfield, Fiona Lees, Ian Zealley, Gordon Houston, Sarah Dickie,
Kirsty Ward, Crawford McGuffie Utility of a Single Early Warning Score in
Patients With Sepsis in the Emergency Department, Emergeny Medicine
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