Optimizing Early Detection: Key Factors Influencing Hospital Early Warning System Implementation – A Systematic Review
DOI:
https://doi.org/10.37287/ijghr.v8i3.1147Keywords:
early warning system, nurse, patient safety cultureAbstract
Early Warning System (EWS) is a clinical tool used to detect early signs of patient deterioration and prevent delayed interventions. Despite broad implementation, challenges persist related to healthcare providers’ readiness, organizational support, system design, and varied care environments. This study aims to identify and analyze factors influencing EWS implementation based on recent empirical evidence to support more effective and sustainable use in healthcare settings. A systematic review was conducted using five electronic databases: PubMed, Scopus, ScienceDirect, SpringerLink and ProQuest. The search employed key terms including “Early Warning System,” “EWS score,” “National Early Warning Score,” “NEWS2,” “hospital,” “implementation,” “adherence,” “barriers,” “facilitators,” and “healthcare professionals.” A total of 1,163 articles were initially identified. Following duplicate removal, title and abstract screening, and full-text assessment in accordance with PRISMA guidelines, 23 peer-reviewed articles met the inclusion criteria. Eligible studies were open-access, published in English between 2018 and 2025, and reported original empirical findings related to EWS implementation. This review was registered with PROSPERO. The included studies identified four major categories of factors influencing EWS implementation: (1) Individual factors, including clinical experience, attitudes, knowledge, and emotional readiness; (2) Organizational factors, such as managerial support, patient safety culture, infrastructure, and institutional policies; (3) Intervention-related factors, including system design, training quality, and integration with information technology; and (4) Environmental factors, encompassing resource availability, facility conditions, and the need for local adaptation. Successful implementation of Early Warning Systems requires a comprehensive and integrated approach. Effectiveness and long-term sustainability are influenced by the extent to which implementation strategies are aligned with local clinical contexts, supported by structured training programs, embedded within a strong patient safety culture, and reinforced through multidisciplinary collaboration.
References
Agulnik, A., Ferrara, G., Puerto-Torres, M., Gillipelli, S. R., Elish, P., Muniz-Talavera, H., Gonzalez-Ruiz, A., Armenta, M., Barra, C., Diaz, R., Hernandez, C., Juárez Tobias, S., De Jesus Loeza, J., Mendez, A., Montalvo, E., Penafiel, E., Pineda, E., & Graetz, D. E. (2022). Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings. JAMA Network Open, 5(3), E221547. https://doi.org/10.1001/jamanetworkopen.2022.1547
Agulnik, A., Muniz-Talavera, H., Pham, L. T. D., Chen, Y., Carrillo, A. K., Cárdenas-Aguirre, A., Gonzalez Ruiz, A., Garza, M., Conde Morelos Zaragoza, T. M., Soberanis Vasquez, D. J., Méndez-Aceituno, A., Acuña-Aguirre, C., Alfonso-Carreras, Y., Alvarez Arellano, S. Y., Andrade Sarmiento, L. A., Batista, R., Blasco Arriaga, E. E., Calderon, P., Chavez Rios, M., … Rodriguez-Galindo, C. (2023). Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study. The Lancet Oncology, 24(9), 978–988. https://doi.org/10.1016/S1470-2045(23)00285-1
Agulnik, A., Schmidt-Grimminger, G., Ferrara, G., Puerto-Torres, M., Gillipelli, S. R., Elish, P., Muniz-Talavera, H., Gonzalez-Ruiz, A., Armenta, M., Barra, C., Diaz-Coronado, R., Hernandez, C., Juarez, S., Loeza, J. de J., Mendez, A., Montalvo, E., Penafiel, E., Pineda, E., Graetz, D. E., & McKay, V. (2022). Challenges to sustainability of pediatric early warning systems (PEWS) in low-resource hospitals in Latin America. Frontiers in Health Services, 2, 1004805. https://doi.org/10.3389/frhs.2022.1004805
Astuti, L. P., Trisyani, Y., & Mirwanti, R. (2023). Implementasi Early Warning System (Ews) dalam Mendeteksi Perburukan Akut pada Pasien Dewasa di Ruang Rawat Inap Rumah Sakit. Journal of Telenursing (JOTING), 5(2), 1590–1603. https://doi.org/10.31539/joting.v5i2.6356
Azyabi, A., Karwowski, W., & Davahli, M. R. (2021). Assessing Patient Safety Culture in Hospital Settings. International Journal of Environmental Research and Public Health 2021, Vol. 18, Page 2466, 18(5), 2466. https://doi.org/10.3390/IJERPH18052466
Bedoya, A. D., Clement, M. E., Phelan, M., Steorts, R. C., O’Brien, C., & Goldstein, B. A. (2019). Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration. Critical Care Medicine, 47(1), 49–55. https://doi.org/10.1097/CCM.0000000000003439
Bingham, G., Fossum, M., Barratt, M., & Bucknall, T. (2015). Clinical review criteria and medical emergency teams: evaluating a two-tier rapid response system. Critical Care and Resuscitation, 17(3), 167–173. https://doi.org/10.1016/S1441-2772(23)01484-9
Blythe, R., Naicker, S., White, N., Donovan, R., Scott, I. A., McKelliget, A., & McPhail, S. M. (2024). Clinician perspectives and recommendations regarding design of clinical prediction models for deteriorating patients in acute care. BMC Medical Informatics and Decision Making, 24(1). https://doi.org/10.1186/S12911-024-02647-4
Brangan, E., Banks, J., Brant, H., Pullyblank, A., Le Roux, H., & Redwood, S. (2018). Using the National Early Warning Score (NEWS) outside acute hospital settings: A qualitative study of staff experiences in the West of England. BMJ Open, 8(10). https://doi.org/10.1136/bmjopen-2018-022528
Braun, E. J., Singh, S., Penlesky, A. C., Strong, E. A., Holt, J. M., Fletcher, K. E., Stadler, M. E., Nattinger, A. B., & Crotty, B. H. (2022). Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. BMJ Quality & Safety. https://doi.org/https://doi.org/10.1136/bmjqs-2021-014498
Carter, B., Saron, H., Blake, L., Eyton-Chong, C. K., Dee, S., Evans, L., Harris, J., Hughes, H., Jones, D., Lambert, C., Lane, S., Mehta, F., Peak, M., Preston, J., Siner, S., Sefton, G., & Carrol, E. D. (2022). Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals. PLoS ONE, 17(9 September). https://doi.org/10.1371/journal.pone.0273666
Carter, B., Saron, H., Siner, S., Preston, J., Peak, M., Mehta, F., Lane, S., Lambert, C., Jones, D., Hughes, H., Harris, J., Evans, L., Dee, S., Eyton-Chong, C.-K., Sefton, G., & Carrol, E. D. (2022). Health professionals’ initial experiences and perceptions of the acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): a qualitative interview study. BMC Pediatrics, 22, 1–12. https://doi.org/https://doi.org/10.1186/s12887-022-03411-1
Connor, J., Flenady, T., Dwyer, T., & Massey, D. (2025). Acknowledging: A classic grounded theory explaining how nurses’ employ clinical judgement when complying with early warning system protocols. International Journal of Nursing Studies, 163, 104989. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2024.104989
de Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care, 17(3), 216. https://doi.org/10.1136/qshc.2007.023622
Dryden-Palmer, K., Berta, W. B., & Parshuram, C. S. (2022). Implementing a complex hospital innovation: conceptual underpinnings, program design and implementation of a complex innovation in an international multi-site hospital trial. BMC Health Services Research, 22(1). https://doi.org/10.1186/S12913-022-08768-8
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. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2024.104846
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. https://doi.org/10.1016/j.ijnurstu.2020.103849
Ehara, J., Masuda, Y., Hayashi, K., Norisue, Y., & Fujitani, S. (2024). Efficacy of Early Warning Scores as the Prediction Tool for Detecting Patients With Acute Deterioration in a High Dependent Unit. Cureus. https://doi.org/10.7759/cureus.71971
Flenady, T., Dwyer, T., Sobolewska, A., Lagadec, D. Le, 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). https://doi.org/10.1186/S12913-020-05615-6
García-del-Valle, S., Arnal-Velasco, D., Molina-Mendoza, R., & Gómez-Arnau, J. I. (2021). Update on early warning scores. Best Practice & Research Clinical Anaesthesiology, 35(1), 105–113. https://doi.org/10.1016/J.BPA.2020.12.013
Gawronski, O., Ferro, F., Cecchetti, C., Ciofi Degli Atti, M., Dall’Oglio, I., Tiozzo, E., & Raponi, M. (2021). Adherence to the bedside paediatric early warning system (BedsidePEWS) in a pediatric tertiary care hospital. BMC Health Services Research, 21(1). https://doi.org/10.1186/S12913-021-06809-2
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, 369, m1501. https://doi.org/10.1136/bmj.m1501
Giwangkancana, G., Setiasih, Y., Hasanah, A., Persiyawati, Y., & Wawan, -. (2025). Understanding Code Blue Activations: Insights From Early Warning and Palliative Scores in a Tertiary Hospital. Open Access Emergency Medicine, Volume 17, 43–50. https://doi.org/10.2147/OAEM.S487687
Graverholt, B., Espehaug, B., Ciliska, D., & Potrebny, T. (2024). The effectiveness of a knowledge translation intervention on the implementation of NEWS2 in nursing homes, a pragmatic cluster RCT. Implementation Science , 19(1). https://doi.org/10.1186/S13012-024-01392-6
Hamada, O., Tsutsumi, T., Tsunemitsu, A., Sasaki, N., & Imanaka, Y. (2025). Improving respiratory rate monitoring in general wards following implementation of a rapid response system: a quality improvement initiative. BMJ Open Quality, 14(2). https://doi.org/https://doi.org/10.1136/bmjoq-2024-003218
Lourenço, L. B. de A., Meszaros, M. de J., Silva, M. de F. N., & São-João, T. M. (2023). Nursing Training for Early Clinical Deterioration Risk Assessment: Protocol for an Implementation Study. JMIR Research Protocols, 12, e47293. https://doi.org/10.2196/47293
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. https://doi.org/10.1136/bmj.i2139
Mathukia, C., Fan, W., Vadyak, K., Biege, C., & Krishnamurthy, M. (2015). Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. Journal of Community Hospital Internal Medicine Perspectives, 5(2), 26716. https://doi.org/10.3402/jchimp.v5.26716
McElroy, T., Swartz, E. N., Hassani, K., Waibel, S., Tuff, Y., Marshall, C., Chan, R., Wensley, D., & O’Donnell, M. (2019). Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up. BMC Emergency Medicine, 19(1). https://doi.org/10.1186/S12873-019-0287-5
McKay, V., Carothers, B., Graetz, D., Malone, S., Puerto-Torres, M., Prewitt, K., Cardenas, A., Chen, Y., Devidas, M., Luke, D. A., & Agulnik, A. (2023). Sustainability determinants of an intervention to identify clinical deterioration and improve childhood cancer survival in Latin American hospitals: the INSPIRE study protocol. Implementation Science Communications, 4(1), 141. https://doi.org/10.1186/s43058-023-00519-y
Mikhail, J., & King, L. (2025). Ward-Based Staff Perspectives on Their Preparedness to Recognize Patient Deterioration: An Interpretive Description Study. Journal of Nursing Research, 33(1). https://doi.org/10.1097/jnr.0000000000000658
Mills, D., Schmid, A., Najajreh, M., Nasser, A. Al, Awwad, Y., Qattush, K., Monuteaux, M. C., Hudgins, J., Salman, Z., & Niescierenko, M. (2021). Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine. BMC Health Services Research, 21, 1–8. https://doi.org/https://doi.org/10.1186/s12913-021-07157-x
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group*, t. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Medicine, 151(4), 264–269.
Moore, J., Thomson, D., Pimentil, I., Fekad, B., & Graham, W. (2019). Introduction of a modified obstetric early warning system A (A MOEWSA)A at an Ethiopian referral hospital: A feasibility assessment. BMJ Open Quality, 8(1). https://doi.org/10.1136/bmjoq-2018-000503
Mosadeghrad, A. M. (2014). Factors influencing healthcare service quality. International Journal of Health Policy and Management, 3(2), 77–89. https://doi.org/10.15171/ijhpm.2014.65
Nelson, K., Brooks, M., Mead-Harvey, C., Quill, J., Kiley, B., Peworski, C., Ritchie, A., & Sen, A. (2024). Nurse-led medical emergency response reduces code blue team activations in non-hospitalized patients. Resuscitation Plus, 18, 100642. https://doi.org/https://doi.org/10.1016/j.resplu.2024.100642
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). https://doi.org/10.1186/S12873-021-00403-9
Prastya, A., Mawaddah, N., & Bogohanto, B. (2023). Factor Analysis in the Implementation of Early Warning System Documentation in Psychiatric Hospitals. Indonesian Journal of Occupational Safety and Health, 12(2), 219–226. https://doi.org/10.20473/ijosh.v12i2.2023.219-226
Prihati, D. R., & Wirawati, M. K. (2019). Pengetahuan perawat tentang early warning score dalam penilaian dini kegawatan pasien kritis. Jurnal Keperawatan, 11(4), 237–242.
QY, Q. N., Nursalam, N., & Ahsan, A. (2020). Knowledge and skill in relation to the speed and accuracy of the nurses when assessing using an early warning system (EWS). Jurnal Ners, 15(2).
Rorimpandey, D. (2019). Analysis Of Early Warning System Score Implementation At Inpatient Room In Siloam Hospitals Balikpapan. International Journal of Advanced Research, 7(6), 777–785. https://doi.org/10.21474/IJAR01/9279
Rosakawati. (2019). Analisis Implementasi Early Warning System Di Departemen Rawat Inap Rumah Sakit Mandaya Karawang Tahun 2018. Universitas Indonesia.
Smith, D., Francis, J. J., & Aitken, L. M. (2019). DEveloping a Complex Intervention for DEteriorating patients using theoretical modelling (DECIDE study): Study protocol. Journal of Advanced Nursing, 75(9), 2024–2035. https://doi.org/10.1111/jan.14076
Sujalmo, P., Setiyarini, S., Walsh, K., & Greenwood, M. (2022). Nurses’ Perception On The Initial Implementation Of An Early Warning System: A Mixed-Method Study. Jurnal Keperawatan Soedirman, 17(1), 29–35. https://doi.org/10.20884/1.jks.2022.17.1.4927
Sutton, R. M., Niles, D., French, B., Maltese, M. R., Leffelman, J., EilevstjØnn, J., Wolfe, H., Nishisaki, A., Meaney, P. A., Berg, R. A., & Nadkarni, V. M. (2014). First quantitative analysis of cardiopulmonary resuscitation quality during in-hospital cardiac arrests of young children. Resuscitation, 85(1), 70–74. https://doi.org/10.1016/j.resuscitation.2013.08.014
Swami, T., Shams, A., Mittelstadt, M., Guenther, C., Tse, T., Noor, H., & Shahid, R. (2023). Implementation of early warning system in the clinical teaching unit to reduce unexpected deaths. BMJ Open Quality, 12(2). https://doi.org/10.1136/bmjoq-2022-002194
Ulumiyah, N. H. (2018). MENINGKATKAN MUTU PELAYANAN KESEHATAN DENGAN PENERAPAN UPAYA KESELAMATAN PASIEN DI PUSKESMAS. Jurnal Administrasi Kesehatan Indonesia, 6(2), 149. https://doi.org/10.20473/jaki.v6i2.2018.149-155
van der Fluit, K. S., Boom, M. C., Brandão, M. B., Lopes, G. D., Barreto, P. G., Leite, D. C. F., & Gurgel, R. Q. (2021). How to implement a PEWS in a resource-limited setting: A quantitative analysis of the bedside-PEWS implementation in a hospital in northeast Brazil. Tropical Medicine and International Health, 26(10), 1240–1247. https://doi.org/10.1111/tmi.13646
Woo, M. C., Ferrara, G., Puerto-Torres, M., Gillipelli, S. R., Elish, P., Muniz-Talavera, H., Gonzalez-Ruiz, A., Armenta, M., Barra, C., Diaz-Coronado, R., Hernandez, C., Juarez, S., Loeza, J. de J., Mendez, A., Montalvo, E., Peñafiel, E., Pineda, E., Graetz, D. E., Kortz, T., & Agulnik, A. (2023). Stages of change: Strategies to promote use of a Pediatric Early Warning System in resource-limited pediatric oncology centers. Cancer Medicine, 12(14), 15358–15370. https://doi.org/https://doi.org/10.1002/cam4.6087
World Health Organization. (2019). Global action on patient safety.
World Health Organization. (2023). Patient safety. https://www.who.int/news-room/fact-sheets/detail/patient-safety
Zeng, Z., Li, X., Bai, Y., & Gong, W. (2024). Barriers and facilitators of screening postpartum depression by primary maternal health workers: A mixed methods study based on the normalization process theory. Midwifery, 138. https://doi.org/10.1016/j.midw.2024.104148
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