Applying Early Warning Score (EWS) in hospitals for adult mortality risk factors


  • Purnomo Wahyudi Gadjah Mada University
  • Viky Noviani Hemu viky
  • Suprayogi Universitas Gadjah Mada
  • Sri Setiyarini Universitas Gadjah Mada

Abstract views 23 times


The mortality rate among adult hospital patients is a significant indicator in assessing the quality of care and health services. High mortality rates can affect a hospital's reputation, reduce the credibility of medical personnel, and trigger public anxiety. Failure to recognize the worsening of a patient's condition can delay appropriate life support management. This scoping review aims to identify and analyze the Early Warning Score (EWS) application for adults with risk factors for death in regional general hospitals (RSUD). The scoping review was conducted by searching literature using electronic databases from January 2018-May 2023, such as PubMed, ScienceDirect, LibMed UGM, and hand searching. Relevant articles were selected based on inclusion criteria. The results contained two main themes: factors related to mortality in adult patients and the benefits of implementing EWS on the clinical outcomes of adult patients. Implementing EWS in adult patients with high-risk factors for mortality at Regional General Hospitals can help identify the worsening of the patient's condition early, reducing the risk of death. Increasing awareness of the importance of EWS, EWS training, and consistent use of EWS according to hospital protocols can help reduce mortality and improve overall patient clinical outcomes.


Alam, N., Hobbelink, E. L., van Tienhoven, A. J., van de Ven, P. M., Jansma, E. P., & Nanayakkara, P. W. B. (2014). The impact of using the Early Warning Score (EWS) on patient outcomes: A systematic review. Resuscitation, 85(5), 587–594.

Al-Jabri, F., Kvist, T., Sund, R., & Turunen, H. (2021). Quality of care and patient safety at healthcare institutions in Oman: Quantitative study of the perspectives of patients and healthcare professionals. BMC Health Services Research, 21(1), 1109.

Andersen, L. W., Kim, W. Y., Chase, M., Berg, K. M., Mortensen, S. J., Moskowitz, A., Novack, V., Cocchi, M. N., Donnino, M. W., & American Heart Association’s Get With the Guidelines(®) – Resuscitation Investigators. (2016). The prevalence and significance of abnormal vital signs prior to in-hospital cardiac arrest. Resuscitation, 98, 112–117.

Arévalo-Buitrago, P., Morales-Cané, I., Olivares Luque, E., Guler, I., Rodríguez-Borrego, M. A., & López-Soto, P. J. (2021). The predictive power of early-warning scores used in hospital emergency departments: A systematic review and meta-analysis. Emergencias: Revista De La Sociedad Espanola De Medicina De Emergencias, 33(5), 374–381.

Bell, D., Baker, J., Williams, C., & Bassin, L. (2021). A Trend-Based Early Warning Score Can Be Implemented in a Hospital Electronic Medical Record to Effectively Predict Inpatient Deterioration. Critical Care Medicine, 49(10), e961–e967.

Credland, N., Dyson, J., & Johnson, M. J. (2018). What are the patterns of compliance with Early Warning Track and Trigger Tools: A narrative review. Applied Nursing Research: ANR, 44, 39–47.

Dagenais, G. R., Leong, D. P., Rangarajan, S., Lanas, F., Lopez-Jaramillo, P., Gupta, R., Diaz, R., Avezum, A., Oliveira, G. B. F., Wielgosz, A., Parambath, S. R., Mony, P., Alhabib, K. F., Temizhan, A., Ismail, N., Chifamba, J., Yeates, K., Khatib, R., Rahman, O., … Yusuf, S. (2020). Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): A prospective cohort study. The Lancet, 395(10226), 785–794.

Dewi, B. A. M., Susila, I. M. D. P., & Darmawan3, A. A. K. N. (2020). Pengaruh Penggunaan Adult Early Warning Scoring (AEWS) Terhadap Tingkat Mortalitas di RSUD Bali Mandara. Jurnal Kesehatan Saelmakers PERDANA (JKSP), 3(2), Article 2.

Eddahchouri, Y., Koeneman, M., Plokker, M., Brouwer, E., van de Belt, T. H., van Goor, H., & Bredie, S. J. (2021). Low compliance to a vital sign safety protocol on general hospital wards: A retrospective cohort study. International Journal of Nursing Studies, 115, 103849.

Eddahchouri, Y., Peelen, R. V., Koeneman, M., Touw, H. R. W., van Goor, H., & Bredie, S. J. H. (2022). Effect of continuous wireless vital sign monitoring on unplanned ICU admissions and rapid response team calls: A before-and-after study. British Journal of Anaesthesia, 128(5), 857–863.

Eldawlatly, A., Alshehri, H., Alqahtani, A., Ahmad, A., Al-Dammas, F., & Marzouk, A. (2018). Appearance of Population, Intervention, Comparison, and Outcome as research question in the title of articles of three different anesthesia journals: A pilot study. Saudi Journal of Anaesthesia, 12(2), 283–286.

Elliott, D., Allen, E., Perry, L., Fry, M., Duffield, C., Gallagher, R., Iedema, R., McKinley, S., & Roche, M. (2015). Clinical user experiences of observation and response charts: Focus group findings of using a new format chart incorporating a track and trigger system. BMJ Quality & Safety, 24(1), 65–75.

English, M., Mwaniki, P., Julius, T., Chepkirui, M., Gathara, D., Ouma, P. O., Cherutich, P., Okiro, E. A., & Snow, R. W. (2018). Hospital Mortality – a neglected but rich source of information supporting the transition to higher quality health systems in low and middle income countries. BMC Medicine, 16(1), 32.

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, 736.

Fox, A., & Elliott, N. (2015). Early Warning Scores: A sign of deterioration in patients and systems. Nursing Management (Harrow, London, England : 1994), 22, 26–31.

Fu, L.-H., Schwartz, J., Moy, A., Knaplund, C., Kang, M.-J., Schnock, K. O., Garcia, J. P., Jia, H., Dykes, P. C., Cato, K., Albers, D., & Rossetti, S. C. (2020). Development and Validation of Early Warning Score System: A Systematic Literature Review. Journal of Biomedical Informatics, 105, 103410.

Gielen, A., Koekkoek, K., van der Steen, M., Looijen, M., & van Zanten, A. R. H. (2021). Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality. The Western Journal of Emergency Medicine, 22(5), 1131–1138.

Gordo, F., & Molina, R. (2018). Evolution to the early detection of severity. Where are we going? Medicina Intensiva (English Edition), 42(1), 47–49.

Hidayat, D. I., Agushybana, F., & Nugraheni, S. A. (2020). Early Warning System pada Perubahan Klinis Pasien terhadap Mutu Pelayanan Rawat Inap. HIGEIA (Journal of Public Health Research and Development), 4(3), Article 3.

Hogan, H., Zipfel, R., Neuburger, J., Hutchings, A., Darzi, A., & Black, N. (2015). Avoidability of hospital deaths and association with hospital-wide mortality ratios: Retrospective case record review and regression analysis. BMJ (Clinical Research Ed.), 351, h3239.

Holland, M., & Kellett, J. (2023). The United Kingdom’s National Early Warning Score: Should everyone use it? A narrative review. Internal and Emergency Medicine, 18(2), 573–583.

Kobewka, D. M., van Walraven, C., Turnbull, J., Worthington, J., Calder, L., & Forster, A. (2017). Quality gaps identified through mortality review. BMJ Quality & Safety, 26(2), 141–149.

Komisi Akreditasi Rumah Sakit. (2017). Standar Nasional Akreditasi Rumah Sakit, Edisi 1 (1st ed.). Komisi Akreditasi Rumah Sakit.

Le Lagadec, M. D., & Dwyer, T. (2017). Scoping review: The use of early warning systems for the identification of in-hospital patients at risk of deterioration. Australian Critical Care, 30(4), 211–218.

Millizia, A., Rizka, A., & Mellaratna, W. P. (2023). Time Saving is Life Saving: Pelatihan Early Warning Scoring System dan Code Blue untuk Tenaga Kesehatan Ruang Rawat Inap RSUD Cut Meutia Aceh Utara | Millizia | Jurnal Malikussaleh Mengabdi. Jurnal Malikussaleh Mengabdi, 2, 242–250. 29103/jmm.v2n1.9397

Nagarajah, S., Krzyzanowska, M. K., & Murphy, T. (2022). Early Warning Scores and Their Application in the Inpatient Oncology Settings. JCO Oncology Practice, 18(6), 465–473.

O’Neill, S. M., Clyne, B., Bell, M., Casey, A., Leen, B., Smith, S. M., Ryan, M., & O’Neill, M. (2021). Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. BMC Emergency Medicine, 21(1), 15.

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. The BMJ, 372.

Perkins, G. D., Graesner, J.-T., Semeraro, F., Olasveengen, T., Soar, J., Lott, C., Van de Voorde, P., Madar, J., Zideman, D., Mentzelopoulos, S., Bossaert, L., Greif, R., Monsieurs, K., Svavarsdóttir, H., Nolan, J. P., & European Resuscitation Council Guideline Collaborators. (2021). European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation, 161, 1–60.

Petersen, J. A. (2018). Early Warning Score challenges and opportunities in the care of deteriorating patients. Danish Medical Journal, 65(2), B5439.

Petersen, J. A., Mackel, R., Antonsen, K., & Rasmussen, L. S. (2014). Serious adverse events in a hospital using Early Warning Score—What went wrong? Resuscitation, 85(12), 1699–1703.

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, 17, 36.

Rajagukguk, C. R., & Widani, N. L. (2020). Faktor-Faktor yang Berhubungan dengan Kepatuhan Pelaksanaan Monitoring Early Warning Score. Carolus Journal of Nursing, 2(2), Article 2.

Ramadhan, M. D. (2019). Hubungan Penerapan Early Warning Score (EWS) dengan Clinical outcomes Pasien di Instalasi Rawat Inap Dewasa RSUP Dr. Sardjito Yogyakarta [Universitas Gadjah Mada].

Salih, S. A., Abdelkader Reshia, F. A., Bashir, W. A. H., Omar, A. M., & Ahmed Elwasefy, S. (2021). Patient safety attitude and associated factors among nurses at Mansoura University Hospital: A cross sectional study. International Journal of Africa Nursing Sciences, 14, 100287.

Samani, S., & Rattani, S. A. (2023). Recognizing Early Warning Signs (EWS) in Patients Is Critically Important. Open Journal of Nursing, 13(1), Article 1.

Schmidt, P. E., Meredith, P., Prytherch, D. R., Watson, D., Watson, V., Killen, R. M., Greengross, P., Mohammed, M. A., & Smith, G. B. (2015). Impact of introducing an electronic physiological surveillance system on hospital mortality. BMJ Quality & Safety, 24(1), 10–20.

Semeraro, F., Greif, R., Böttiger, B. W., Burkart, R., Cimpoesu, D., Georgiou, M., Yeung, J., Lippert, F., S Lockey, A., Olasveengen, T. M., Ristagno, G., Schlieber, J., Schnaubelt, S., Scapigliati, A., & G Monsieurs, K. (2021). European Resuscitation Council Guidelines 2021: Systems saving lives. Resuscitation, 161, 80–97.

Smith, G. B., Prytherch, D. R., Meredith, P., Schmidt, P. E., & Featherstone, P. I. (2013). The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death. Resuscitation, 84(4), 465–470.

Smith, M. E. B., Chiovaro, J. C., O’Neil, M., Kansagara, D., Quiñones, A. R., Freeman, M., Motu’apuaka, M. L., & Slatore, C. G. (2014). Early warning system scores for clinical deterioration in hospitalized patients: A systematic review. Annals of the American Thoracic Society, 11(9), 1454–1465.

Stafseth, S. K., Grønbeck, S., Lien, T., Randen, I., & Lerdal, A. (2016). The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: An exploratory study. Intensive & Critical Care Nursing, 34, 25–33.


Sutrisno, S., Pramusinto, H., & Setiyarini, S. (2022). Analisis Faktor Risiko Ketidakpatuhan Penerapan Early Warning Score Terhadap Mortalitas Pasien. Jurnal Ilmiah Keperawatan, 17(2), Article 2.

Zaenal. (2022). Pengaruh Kebijakan dan Pengawasan terhadap Penerapan Pencegahan dan Pengendalian Infeksi Nosokomial di RSUD Kota Makassar | Syntax Literate ; Jurnal Ilmiah Indonesia. Jurnal Ilmiah Indonesia, 7(Spesial Issue Syntax Literate).






Literature Review