Marjon Borgert

35 Standardized measurement of the Modified Early Warning Score were able to stay on the ward more frequently in November compared to September (70% versus 27%), may substantiate this claim and could re ect earlier detection. A major strength of this study is the completeness of data acquisition from nursing charts during the weeks of measurement and thus the ability to review the actually provided care. As this study depends on records kept by nurses, some information bias may be present. However, this cohort represents all admitted patients and not a selection of patients that experienced an AE. This enables a realistic description of the alertness of nursing sta beyond the few hours preceding an AE. An important limitation of this study is the single centre setting which possibly limits its external validity. 36 The exclusion of measurements in which the patient was absent from the ward for a signi cant part of the day, may have resulted in an underestimation of our ndings since hypothetically speaking, a patient may have received an intervention due to clinical deterioration. Also the fact that we started collecting data shortly after having introduced the RRS may have led to an underestimation of our results since one can question if the RRS was already most e ective at that point in time. Ideally, the implementation phase should have been longer; time and money constrains led to the decision for a three-month period. Another limitation is that measurement of vital signs, three times daily, without MEWS calculation might also lead to increased awareness of deteriorating patients. Finally, since strati cation of wards was only for medical/surgical specialty and not for other possibly in uencing factors such as severity of illness, our ndings regarding clinical e ectiveness have to be weighted accordingly. The ndings of our study have implications for future work and might favour changing to electronic medical record keeping. Recent evidence from the UK shows better completeness of vitals signs and scores with an electronic vital sign assessment chart. 37 Partial automation of responses and standard operating procedures as used in the VITAL care study may o er new opportunities to improve problems in the current system. 38 Opportunities to detect deterioration depend inmany cases on recording vital signs. Automated systems will allow an even greater frequency, thus potentially further reducing the number of ‘missed opportunities’ due to lack of measurements. In order to understand con icting scienti c evidence of RRS processes measurements need to go beyond RRT activation rates to understand why clinical outcomes improve in some studies but not in others. Institutions with a RRS should describe local algorithms for measurements of vital signs and monitor compliance in order to understand the level of performance of their RRT.