Acute functional decline in older home nursing care patients: Using the Modified Early Warning Score to support clinical reasoning and decision-making in community care. A mixed methods study

Abstract

The overall aim was to describe the state of health and clinical trajectories of older home nursing care patients with suspected acute functional decline and factors influencing the trajectories, and to explore the impact of the Modified Early Warning Score (MEWS) on health care personnel’s clinical reasoning and decision-making processes when assessing older home nursing care patients with suspected acute functional decline. Jeppestøl and colleagues collected and analyzed demographic, health-related, and clinical data from older home nursing care patients’ electronic patient records after an initial episode of suspected acute functional decline in which MEWS was recorded. By conducting semi-structured mixed focus groups, Jeppestøl and colleagues also explored registered nurses’ and general practitioners’ experiences and perceptions regarding the use of MEWS to support clinical reasoning and decisions when assessing suspected acute functional decline in older home nursing care patients. In this mixed methods study, Jeppestøl concluded that older home nursing care patients had complex health conditions and received comprehensive community health care services and that the majority of the patients were observed or treated in the home or within the community care. Demographic, social and clinical factors were associated with higher levels of clinical responses, final level of community care and death in cases where acute functional decline was suspected. Findings from patient records and health care personnel’s experiences clearly show that MEWS and clinical judgment supported health care personnel’s escalation of clinical responses to a great extent, and contributed with support for health care personnel to follow-up and keep older home nursing care patients with unstable and complex health conditions at home. However, the present study’s findings also clearly show that MEWS, with its’ current reference values and trigger recommendations, is not appropriate for this patient group and there is need for adjustments to trigger appropriate and safe responses when assessing older patients in home nursing care.