Faktor-faktor yang memengaruhi pelaksanaan tindak lanjut early warning system di rumah sakit: A scoping review
DOI: https://doi.org/10.33024/hjk.v20i6.3840
Clinical Deterioration Early Warning System Escalation of Care Implementation Patient Safety
Abstract
Background: The Early Warning System (EWS) is an early detection system designed to identify deterioration in patients’ clinical conditions through the monitoring of physiological parameters. However, the effectiveness of EWS depends not only on its ability to detect clinical deterioration but also on the appropriate implementation of subsequent follow-up actions, including escalation of care. Evidence regarding the factors influencing the implementation of EWS follow-up actions remains fragmented and has not been comprehensively synthesized.
Purpose: To identify, map, and synthesize scientific evidence regarding the factors influencing the implementation of EWS follow-up actions in hospital settings.
Method: This scoping review was conducted based on the Arksey and O’Malley framework, as refined by Levac et al., and reported in accordance with the PRISMA-ScR guidelines. A literature search was conducted in Scopus, PubMed, and EBSCOhost for English-language articles published between 2015 and 2026. Study selection was guided by the Population–Concept–Context (PCC) framework. Data were extracted using a standardized data extraction form and analyzed narratively through thematic analysis.
Results: Eleven studies were included from 6,126 records identified through the literature search. Factors influencing the implementation of EWS follow-up actions were categorized into individual, team, organizational, and system-level factors. Key facilitating factors included healthcare professionals’ clinical competence and experience, clinical judgment, self-confidence, effective multidisciplinary communication and collaboration, continuous training, clear escalation protocols, and integration of EWS with electronic medical records. The most frequently reported barriers included high workload, inadequate staffing, hierarchical cultures in clinical decision-making, ineffective interprofessional communication, poor adherence to escalation protocols, inaccurate documentation, and challenges in implementing EWS across different hospital care settings.
Conclusion: The implementation of follow-up actions based on EWS is influenced by complex interactions among individual, team, organizational, and system-level factors. Optimizing EWS implementation requires a multicomponent approach that strengthens healthcare professionals’ competence, promotes a patient safety culture, improves interprofessional communication, supports effective clinical leadership, ensures adequate resources, and leverages integrated digital technologies to facilitate timely escalation of care and enhance patient safety.
Keywords: Clinical Deterioration; Early Warning System; Escalation of Care; Implementation; Patient Safety.
Downloads
References
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology: Theory and Practice, 8(1), 19–32.
Burke, C., & Conway, N. Y. (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.
Cardona-Morrell, M., Prgomet, M., Lake, R., Nicholson, M., Harrison, R., Long, J., Westbrook, J., Braithwaite, J., & Hillman, K. (2016). Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice. International journal of nursing studies, 56, 9–16.
Considine, J., Jones, D., Pilcher, D., & Currey, J. (2016). Patient physiological status at the emergency department-ward interface and emergency calls for clinical deterioration during early hospital admission. Journal of advanced nursing, 72(6), 1287–1300.
Dalton, M., Harrison, J., Malin, A., & Leavey, C. (2018). Factors that influence nurses’ response to acute deterioration. British Journal of Nursing, 27(4), 212–216.
De Meester, K., Van Bogaert, P., Clarke, S. P., & Bossaert, L. (2013). In-hospital mortality after serious adverse events on medical and surgical nursing units: a mixed methods study. Journal of clinical nursing, 22(15-16), 2308–2317.
Dwyer, T., Flenady, T., Signal, T., Boyle, C. M., Connor, J., Le Lagadec, D., Goodwin, B., & Browne, M. (2024). A theoretical framework for identifying sociocultural factors that influence nurses’ compliance with early warning systems for acute clinical deterioration: A cross-sectional survey. International Journal of Nursing Studies, 158, 104846.
Flenady, T., Dwyer, T., Sobolewska, A., Lagadec, D. L., 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(1), 736.
Gerry, S., Bonnici, T., Birks, J., Kirtley, S., Virdee, P. S., Watkinson, P. J., & Collins, G. S. (2020). Early warning scores for detecting deterioration in adult hospital patients: systematic review and critical appraisal of methodology. BMJ (Clinical research ed.), 369, m1501.
Jones, D., Mitchell, I., Hillman, K., & Story, D. (2013). Defining clinical deterioration. Resuscitation, 84(8), 1029–1034.
Kolic, I., Crane, S., McCartney, S., Perkins, Z., & Taylor, A. (2015). Factors affecting response to national early warning score (NEWS). Resuscitation, 90, 85-90.
Leenen, J. P., & Mondria, C. L. (2024). Heliyon Variation in nurses ’ compliance with an Early Warning Score protocol : A retrospective cohort study. Heliyon, 10(16), e36147.
Le Lagadec, M. D., Massey, D., Byrne, L., Connor, J., & Flenady, T. (2025). Nurse by numbers: The impact of early warning systems on order thinking: A quantitative study. Journal of Advanced Nursing, 81(12), 5342–5352.
Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5(1), 1–9.
Ludikhuize, J., Smorenburg, S. M., de Rooij, S. E., & de Jonge, E. (2012). Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. Journal of critical care, 27(4), 424-e7.
Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing open, 4(1), 6-23.
McGaughey, J., Alderdice, F., Fowler, R., Kapila, A., Mayhew, A., & Moutray, M. (2007). Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. The Cochrane database of systematic reviews, (3), CD005529.
Muralitharan, S., Nelson, W., Di, S., McGillion, M., Devereaux, P. J., Barr, N. G., & Petch, J. (2021). Machine learning–based early warning systems for clinical deterioration: systematic scoping review. Journal of medical Internet research, 23(2), e25187.
Nadaf, C., Bench, S., Halpin, Y., & Terry, L. (2025). Critical Points of Risk in Registered Nurses ’ Use of a National Early Warning Score — Perceptions and Challenges. Journal of Advanced Nursing, 81, 4871–4882.
Petersen, J. A., Rasmussen, L. S., & Rydahl-hansen, S. (2017). Barriers and facilitating factors related to use of early warning score among acute care nurses : a qualitative study. BMC Emergency Medicine, 1–9.
Royal College of Physicians. (2017). National Early Warning Score (NEWS2): Standardising the assessment of acute-illness severity in the NHS. Royal College of Physicians. Diakses dari: https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2?utm_source=chatgpt.com
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(7–8), 1187–1194.
World Health Organization. (2021). Global patient safety action plan 2021–2030: Towards eliminating avoidable harm in health care. Diakses dari: https://www.who.int/publications/i/item/9789240032705.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Holistik Jurnal Kesehatan
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
