International Emergency Nursing

The introduction of the Early Warning Score in the Emergency Department: A retrospective cohort study


  • Following the introduction of the EWS in the ED, identification of the most serious patients (i.e. MTS 1) remained stable, however, staff were more likely to place other patients in a higher risk category.
  • Post EWS implementation, patients allocated an MTS of 2–5 waited significantly longer to see a clinician and overall spent a longer period of time in the ED.
  • Once introduced, staff were consistent in how they approached the allocation of MTS in conjunction with the EWS.
  • The effective and sustained combined use of the MTS and EWS in the ED requires resources in terms of increased bed capacity and experienced clinical staff.

The combined use of the Manchester Triage System (MTS) with the Early Warning Score (EWS) may be useful in ensuring both appropriate prioritisation and continued monitoring in the Emergency Department (ED) leading to early intervention for deteriorating patients thus improving patient outcomes especially in overcrowded EDs.


  • Determine the effect of the EWS and MTS on accuracy of the MTS and ED waiting times.


  • A retrospective cohort chart review of all adult patients who presented to the ED in one large hospital in Ireland (n = 10,048) at three time points between 1st September 2015-30th September 2016; 3 months prior to EWS introduction, implementation month and 9 months post-implementation.


  • Patients were significantly more likely to be categorised as an MTS category 2 (rather than 3–5) after the EWS was introduced (p < 0.001). Waiting times between triage and clinician review (p < 0.05) increased as did total time in the ED (p > 0.001). A similar finding was observed for patients with an MTS of 3–5.


  • Although positive in terms of patient outcomes, the effective and sustained combined use of the MTS and EWS requires increased bed capacity and experienced clinical staff to ensure that the ED journey time reduced rather than increased.