Early 


Warning 

SCORE

a scorecard that save lives

Francesco Barbero, RN CCNS

INTERNATIONAL SOS(- NIUGINI
 What the literature says:

- 5% of deaths in hospital are preventable

- nearly a third of these deaths are

caused by poor clinical monitoring

davies, 2012
 Early recognition of
critically ill patients

- Hypoxia & hypotension are common warning

signs

MOST cardiac arrests

are predictable!
 Why do we use an EWS?

For early recognition of critical ill patients.

This is key because delays in referral lead to
higher level of care
 THE EWS: how?!?

- COMPLETE AND RECORD Observations AS normal

- score each observation using the parameters

established by the hospital’s policy

- add up the total score and if it exceed the

normal range, activate the right interventions
 Who should have an EWS?

- All adult in-patients: every patient, every time

- any patient attending the hospital for a
procedure which necessitate their
observations being taken
- all patients over 16 yO

A DIFFERENT EWS MUST BE USED WITH CHILDREN

 Who should have an EWS?

ALL PATIENTS BEING TRANSFERRED FROM:

- EMERGENCY DEPARTMENT
- THEATRE / RECOVERY
- ACUTE MEDICINE / HIGH DEPENDENCY UNIT
- LABOUR WARD

THEN RETAKE ON ARRIVAL TO YOUR CLINICAL AREA.

 EWS parameters

3 2 1 0 1 2 3
Respiratory Less than 8 9-14 15-20 21-29 More than 30
Rate
per minute
Heart Rate Less than 40 40-50 51-100 101-110 111-129 More than
129
per minute
Systolic Blood Less than 70 71-80 81-100 101-199 More than
200
Pressure
Conscious Unresponsive Responds to Responds to Alert New Agitation
Pain Voice Confusion
Level
(AVPU)
Temperature °C Less than 35.1-36 36.1-38 38.1-38.5 More than
35.0 38.6
HIGH EWS SCORE . . .
WHAT DOES THAT MEAN?
ALTERED HEART RATE, RESPIRATORY RATE,
TEMPERATURE OR BLOOD PRESSURE CAN be caused by:

- infection - exposure
- shock - anxiety
- cardiac arrhythmia - smoking
- dehydration - exertion
- medications - pre-existing medical
- pain conditions (COPD, etc)
- anaphylaxis
- bleeding
EWS CHART
 EWS CHART - Escalation

SCORE 0-2

Continue to monitor the patient’s vital signs at

the prescribed frequency

- frequency of the observations should be clearly

documented on the patient observation charT
- IF score 2, inform the nurse responsible of the patient’s
care
 EWS CHART - Escalation

SCORE 3

increase the frequency of the observations to

every 2 hours for three times, calculate the
ews each time.
INFORM TREATING PHYSICIAN.
 EWS CHART - Escalation

SCORE 4

increase the frequency of the observations to

every 2 hours for three times, calculate the
ews each time. monitor urinary output.
TREATING PHYSICIAN must REVIEW THE PATIENT at
this stage.
 EWS CHART - Escalation

SCORE 5

call treating physician STAT.

increase the frequency of the observations to
every 1 hour & monitor urinary output.
if patient’s score remain 5 for three consecutive
readings, consider transfer to higher level of
care.
 EWS CHART - Escalation

SCORE 6
or more

call treating physician & Emergency team.

continue to monitor patient’s observations
every 30 minutes until EWS below 4.
consider transfer to higher level of care.
 EWS CHART - Escalation

SCORE WHO ACTION

0-2 NURSE CHW Continue PRESCRIBED monitoring

3 NURSE CHW INFORM PHYSICIAN

Increase VS frequency to q 2 hrs

PHYSICIAN MUST REVIEW the patient

4 DOCTOR NURSE CHW MONITOR urinary output
Increase VS frequency to q 2 hrs x 3

5 DOCTOR NURSE CHW call physician STAT. INFORM EMERGENCY TEAM.

Increase VS frequency to q 1 hr

CALL EMERGENCY TEAM.

6 EMERGENCY TEAM Recommend transfer to higher level of care.
DOCTOR NURSE CHW VS EVERY 30 MIN UNTIL SCORE < 4
 EWS CHART - Escalation

IF SCORES between 3-5 AND CONCERN REMAINS in

spite of medical intervention or patient does
not improve:

- CALL PHYSICIAN
- CALL EMERGENCY TEAM
EWS CHART - Escalation

SCORE 6
or more

THE PATIENT IS UNDERGOING an acute life

threatening event and is at risk of requiring
imminent emergency resuscitation!
EWS CHART - Escalation

SCORE 6
or more

CALL EMERGENCY TEAM

SBAR REPORTING TOOL

To improve the communication about patients

between all health providers, use the I-Sbar
tool before calling:

I: Identify
S: Situation
B: Background
A: Assessment
R: Response
i-SBAR REPORTING TOOL

Identify:
Yourself by name & position
your location (ward, service)
who you’re talking to
patient name, age & sex
i-SBAR REPORTING TOOL

situation:
state the purpose of your call
“ the reason I calling is . . . “
if is urgent say so and reason why
i-SBAR REPORTING TOOL

BACKGROUND
Tell the storY!
current problem & relevant history
relevant test results
i-SBAR REPORTING TOOL

ASSESSMENT
State what you think is going on
most recent vital signs including EWS score
urinary output and any other medical treatment
i-SBAR REPORTING TOOL

REQUEST
If required urgently, say so and reason why
state what you would like to see done (tests, meds)
i-SBAR REPORTING TOOL

document the change in condition

who you spoke to
keep available the medical record
 Summary

• EWS - every patient, every time

• gather all information that you need when
escalating a raised EWS (I-sbar)
• document the details of communication in the
medical notes
Thanks for your attention!