Admissão Doente Critico - Manual Oxford

Admission to critical care
Oxford Handbook of Critical Care

Nursing (2 ed.)
Edited by Heather Baid, Fiona Creed, and Jessica
Hargreaves
Previous Edition (1 ed.)
Publisher: Oxford University Press Print Publication Date: Feb 2016

Print ISBN-13: 9780198701071 Published online: Mar 2016
DOI: 10.1093/med/
9780198701071.001.0001
Chapter: Admission to critical care
Author(s): Heather Baid, Fiona Creed, and Jessica Hargreaves
DOI: 10.1093/med/9780198701071.003.0001
Changes to the delivery of critical care

Preventing admissions to critical care
Levels of care
Admission criteria
Organizing admission into critical care
Changes to the delivery of critical care
Page 1 of 16
The changing face of acute nursing
The face of acute care and critical care has changed substantially over
the last two decades. This change has been influenced by a number of
factors, but perhaps most significantly by the increasing number of
acutely ill patients within the hospital environment. A number of factors
have influenced patient acuity, including:
• an ageing population with increased levels of comorbidity

• use of advanced treatment modalities and technologies
• increased complexity of patient needs.
The changes in acuity levels have meant that healthcare providers have
been faced with challenges related to caring for an increasing number of
acutely and critically ill patients.
Over 15 years ago the National Audit Office1 identified a lack of provision
of critical care beds, and reported that demand for critical care beds
often exceeded the number of such beds available. This necessitated an
urgent review of critical care provision.
The publication of Comprehensive Critical Care: a review of adult critical

care services by the Department of Health2 a year later helped to
redevelop the provision of acute and critical care services in the UK. This
document marked the end of traditional boundaries associated with
critical care, and emphasized the need for a hospital-wide approach to
caring for acutely and critically ill patients.
The vision of comprehensive critical care was that hospitals should meet
the needs of all critically ill patients, not just those in designated critical
care beds, and gave rise to the concept of ‘critical care without walls.’ It
highlighted both the need to radically change critical care provision, and
the need for the following characteristics of a modern critical care
service:
• integration of services beyond the boundaries of critical care units to

allow provision of acute and critical care and the optimization of
resources
• the development of critical care networks to share standards and
protocols and to develop future care provision
• workforce development to ensure that all staff caring for acutely and
critically ill patients have sufficient knowledge and training.
Recognition of deterioration
Alongside the redevelopment of critical care services, problems with the

recognition of deterioration in the patient’s condition were being
highlighted.
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date: 07 June 2021

A seminal study by McQuillan and colleagues3 first introduced the now

well-recognized concept of suboptimal care for acutely ill adults.
Suboptimal care relates to multifactorial issues that contribute to
misdiagnosis, mismanagement, and lack of timely intervention for acutely
ill deteriorating patients. Delays in treating acutely ill patients were
linked to unexpected deaths and unplanned and perhaps preventable
admissions to critical care units.
McQuillan and colleagues’3 study identified that over 50% of patients

encountered suboptimal management prior to admission to critical care
units. Unfortunately, similar statistics are still evident despite ongoing
interventions to improve the situation. The current literature often uses
the term ‘failure to rescue’ to refer to suboptimal care.
Factors related to suboptimal care—or, more recently, ‘failure to rescue’—

include:
• lack of knowledge and lack of experience in dealing with acutely ill

patients
• failure to appreciate the urgency of the need to treat the patient’s
condition
• failure to seek senior or expert advice about the patient’s condition
• lack of senior medical staff involvement
• organizational failings that prevent adequate assessment and
management of the deteriorating patient.
A number of initiatives have been developed to improve recognition and

management of the deteriorating patient. Analysis of the literature
suggests that the number of preventable deaths and unplanned critical
care admissions could be reduced if deteriorating patients were identified
earlier and managed in a timely manner.
References
1 National Audit Office. Critical to Success: the place of efficient and
effective critical care services within the acute hospital. Audit
Commission: London, 1999.
2 Department of Health. Comprehensive Critical Care: a review of adult

critical care services. Department of Health: London, 2000.
3 McQuillan P et al. Confidential inquiry into quality of care before

admission to intensive care. British Medical Journal 1998; 316: 1853–8.
Preventing admissions to critical care
Page 3 of 16

date: 07 June 2021

A number of initiatives have been implemented to help to prevent the

admission of acutely ill patients into critical care units. These initiatives
include:
• development of critical care outreach teams

• development of early warning scores
• utilization of medical emergency teams
• education initiatives.
Critical care outreach
The widespread development of critical care outreach services followed

the publication of Comprehensive Critical Care: a review of adult critical
care services.4 Indeed, the National Institute for Health and Care
Excellence (NICE)5 identified the need to establish outreach services in
all acute hospitals 24 hours a day, 7 days a week.
Outreach teams were initially established with the following key aims:
• to avert admission to critical care units

• to support staff in ward areas
• to provide education programmes for ward-based staff
• to support critical care patients following transfer from critical care,
in order to avert readmissions
• to provide follow-up services on discharge from hospital, to
determine the impact of critical care on the patient.
The implementation of outreach has not been consistent across acute

trusts, and various teams have been developed. These include:
• critical care outreach teams

• patient at-risk teams
• rapid response teams.
Although differences exist between various configurations of critical care

outreach teams, these teams are generally nurse led and have been
introduced to support and help to educate ward nurses when they are
caring for deteriorating and acutely ill patients. Unfortunately there is
little substantive research to support the effectiveness of outreach in
improving patient outcomes. Therefore more research is needed to review
the effectiveness of the role of outreach.6
Early warning scores
These were introduced to try to help ward staff to recognize and respond
to deteriorating patients on general wards. The systems use routine
physiological measurements, and each measurement is given a numerical
value depending on the variation from normal parameters. The individual
Page 4 of 16

date: 07 June 2021

parameter scores are added together and an aggregate score is then

obtained that highlights the need for patient review. Put simply, the
higher the score, the more ill the patient is. The early warning scores are
linked to an escalation process.
Most recently the Royal College of Physicians has been instrumental in

developing a National Early Warning Score (NEWS)7 that is in the process
of being implemented throughout the UK.
This tool has been developed to provide standardization of assessment

and escalation processes throughout NHS trusts. The NEWS system
provides values for each observation recorded (see Table 1.1). The
aggregate NEWS score is then linked to a national escalation policy (see
Table 1.2). It is anticipated that implementation of this system will enable
consistency in detecting and responding to acutely ill patients, and help
to avoid admissions to critical care by identifying deteriorating patients
earlier.
Page 5 of 16

date: 07 June 2021

Table 1.1 NEWS abnormal observation values
3 2 1 1 2 3
Respiratory rate ≤8 9–11 21–24 ≥ 25

(breaths/min)
Heart rate (beats/ ≤ 40 41–50 91–110 111–130 ≥ 131

min)
Systolic blood ≤ 90 91–100 100–110 ≥220

pressure (mmHg)
Temperature (°C) ≤ 35 35.1–36 38.1–39 ≥ 39.1
Oxygen saturation ≤ 91 92–93 94–95

(%)
Supplemental Yes
oxygen
Level of V, P, or U
consciousness
Page 6 of 16
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and Legal Notice).
date: 07 June 2021

Table 1.2 NEWS escalation tool
NEWS score Frequency of Clinical response

monitoring
0 Minimum of 12- Continue routine NEWS

hourly monitoring
Total: 1–4 Minimum of 4- to Inform registered nurse

6-hourly
Total: 5 or Hourly Inform medical team

moreor3 in one observations urgently
parameter Urgent assessment by
clinician with core
competencies
Monitoring required
Total: 7 or Continuous Immediately inform

more observations specialist registrar
Emergency assessment
by staff with critical
care competencies
Consider move to higher
level of care
Medical emergency teams and emergency response teams
Medical emergency teams have been developed in many NHS trusts to

respond immediately to a medical emergency. It is thought that a rapid
response to a deteriorating patient may provide the opportunity to
intervene and quickly treat symptoms. This may help to avert cardiac
arrests, further deterioration, and subsequent admission to critical care
units.
Medical emergency teams normally consist of doctors and nurses who

possess advanced life support skills. The aim of the team is to respond
early to patient deterioration and provide an immediate coordinated
response for the acutely ill deteriorating patient. Calls to the team may be
in response to a trigger from an early warning score (see Table 1.2), or
may be based on a nurse’s or doctor’s concern about the patient.
Although there is no significant research to support these teams yet,

there is compelling evidence that the medical emergency teams may
Page 7 of 16

date: 07 June 2021

improve quality of care for seriously ill patients who are nursed outside
critical care areas.
Education initiatives
Other educational initiatives have also been developed to help to provide

a multidisciplinary approach to assessment and management of the
acutely ill patient .The rationale of these programmes is to provide an
understanding of systematic patient assessment tools (see Chapter 2) and
initial management of the deteriorating patient.
Courses are either multidisciplinary or medically focused, and use a

range of low- to high-fidelity simulation scenarios to teach assessment
and management of the deteriorating patient. These programmes include:
• acute NHS trust in-house training days

• the Acute Life-threatening Events Recognition and Treatment
(ALERT©) programme
• the Acute Illness Management (AIM) course
• Care of the Critically Ill Surgical Patient (CCrISP®)
• Ill Medical Patients Acute Care and Treatment (IMPACT).
References
5 National Institute for Health and Care Excellence (NICE). Acutely Ill
Patients in Hospital: recognition of and response to acute illness in adults
in hospital. CG50. NICE: London, 2007. www.nice.org.uk/guidance/
cg50
6 Rowan K et al. Evaluation of Outreach Services in Critical Care.

National Intensive Care Research and Audit Committee: London, 2009.
7 Royal College of Physicians. National Early Warning Score (NEWS):

standardising the assessment of acute-illness severity in the NHS. Report
of a working party. Royal College of Physicians: London, 2012.
Levels of care
These were first devised in 2000 by the Department of Health8

to help to replace traditional boundaries that labelled patients as critical
care patients or ward patients. Linked to the concept of ‘critical care
without walls’, these levels help to clarify the dependency levels of
patients and assist in informing decision making about the management
of patient care.
Page 8 of 16

date: 07 June 2021

The initial levels were highlighted by the Department of Health (see Table
1.3.). These levels were too simplistic, and were soon superseded by
levels published by the Intensive Care Society,9 which gave further
guidance about what might be appropriate patient management at each
level. The Intensive Care Society levels provide specific examples (see
Table 1.4). Further details of specific examples can be found on the
Intensive Care Society website ( www.ics.ac.uk).
Table 1.3 Levels of care8
Level Descriptor
0 Patients whose needs can be met in a ward environment
1 Patients at risk of deterioration who can be managed in a

ward area with additional advice and support ( this includes
patients recently relocated from higher levels of care)
2 Patients who require detailed observation and support of a

single failing system, or complex post-operative care (again
this includes patients recently relocated from higher levels
of care)
3 Patients who require advanced respiratory support or basic

respiratory support together with support of at least two
organ systems (also includes patients with multi-organ
failure)
Table 1.4 Additional guidance, adapted from Intensive Care Society

levels of care9
Level criteria Selected specific examples*
Level Patients recently Requiring a minimum of 4-

1 discharged from higher hourly observations
level of care Continuous oxygen,
Patients in need of epidurals, patient-
additional monitoring controlled analgesia (PCA),
Patients requiring tracheostomy in situ
critical care support Risk of clinical
deterioration, or patient
has abnormal observations
Level Patients requiring pre- CVS, respiratory, or renal

2 operative optimization optimization
Page 9 of 16

date: 07 June 2021

Patients requiring Major or emergency

extended post- surgery, and risk of
operative care complications
Needing hourly
Patients stepping down
observation and at risk of
from a higher level of
deterioration
care
Non-invasive ventilation;
Patients requiring: intubated to protect airway
Insertion of CVP or arterial
• single organ
line Single vasoactive drug
support
or cardiac output
• basic respiratory monitoring
or CVS support Renal replacement therapy
• advanced CVS CNS depression, ICP
support monitoring, EVD
• renal support Major skin rashes,
exfoliation, burns, or
• neurological
complex dressings
support
• dermatological
support
Level Patients receiving Invasive mechanical

3 advanced respiratory ventilation or
support alone extracorporeal support
Patients receiving Ventilation plus support of
support for a minimum at least one other failing
of two organs system
*Complete list is available on ICS website ( www.ics.ac.uk).
References
9 Intensive Care Society. Levels of Critical Care for Adult Patients.

Intensive Care Society: London, 2009.
Admission criteria
Although the number of critical care beds has increased

steadily over the past decade, there are still situations in which provision
of critical care beds does not meet demand for critical care admission.
Recent statistical evidence from NHS England10 has identified a critical
care bed occupancy rate of 87.8%, suggesting a service that is near to full
Page 10 of 16

date: 07 June 2021

capacity. Shortages of critical care beds may have far-reaching

implications in practice, including:
• reduced access to critical care beds

• enforced transfer of critically ill patients
• cancelled urgent and elective procedures.
As critical care is a limited resource, it needs to target those patients who

are most likely to benefit from admission to critical care units. Although
decisions relating to admission are complex and multifactorial, and it is
difficult to provide clear guidance on admission criteria, it is clear that
decisions relating to admission (or, more importantly, non-admission)
should be based on objective, ethical, and transparent decision-making
processes.11
The General Medical Council (GMC) provides guidance on ethical and

legal aspects of decision making, but it is sometimes difficult to apply
these to critical care patients for whom the level of complexity of needs
and the disease trajectory are not always clear.
A number of guiding principles may be used to assist the decision-making

process, and it is important to remember that admission to a critical care
unit may not be an appropriate decision for all patients. It is
recommended that admission criteria should be available in all critical
care units. It is therefore imperative that any local admissions policies
and guidelines are utilized in conjunction with the critical care admission
team. The critical care consultant’s decision about admission would
always take precedence over the decision of other medical staff.
Guiding principles for admission
Fullerton and Perkins11 suggest that it is useful to:
• review the patient, and establish ongoing comorbidities and

responses to current treatment
• formulate a prognosis
• discuss the risks and associated burdens of treatment with the
patient and their carers
• reach a consensus on the treatment plan, and agree any ceilings to
treatment in advance.
In general, critical care admission is appropriate if:
• the patient’s condition is potentially reversible

• the patient can reasonably be expected to survive the critical care
admission
• there is reasonable doubt about the likely outcome for the patient.
Page 11 of 16

date: 07 June 2021

Factors that may preclude admission to critical care include the following:
• the patient’s condition is likely to be fatal and will not be amenable

to recovery, or has progressed beyond any reasonable likelihood of
recovery
• the patient’s pre-existing comorbidities make the prospect of
recovery very unlikely
• the patient has mental capacity and refuses to be admitted on the
basis of either an advance directive or discussion with the critical care
team.
References
10 NHS England. Critical Care Bed Capacity and Urgent Operations
Cancelled 2013–14 Data. www.england.nhs.uk/statistics/statistical-
work-areas/critical-care-capacity/critical-care-bed-capacity-and-urgent-
operations-cancelled-2013-14-data
11 Fullerton JN and Perkins GD. Who to admit to intensive care? Clinical

Medicine 2011; 11: 601–4.
Organizing admission to critical care
Nursing responsibilities
It is important that the critical care nurse possesses the appropriate

skills, knowledge, and attitudes to safely admit patients to the critical
care unit. The Critical Care Networks-National Nurse Leads (CC3N) have
recently published competencies relating to critical care nursing.12 One
of the Step 1 Competencies relates to admissions to critical care. The key
responsibilities for an effective admission to critical care include:
• safe preparation of the bed area

• safe staffing levels within the intensive care area
• initial assessment and monitoring of the critically ill patient
• communication with the patient and their family or carers.
Safe preparation of the bed area
It is likely that each individual critical care unit will have an admission
protocol describing in detail how to prepare adequately for admission of a
patient to critical care. If such a protocol is available it should be
followed. There are several guiding principles for preparing the bed area:
• Follow local guidance relating to appropriate cleaning of the area to

prevent cross-contamination from the previous patient in that bed
area. Personal protective equipment should be readily available at
each bed area.
Page 12 of 16

date: 07 June 2021

• Prepare any equipment that will be required for care of the patient.
This should be ready to use and safety checks completed according to
local protocols. Equipment that is likely to be needed for most patients
includes an appropriate ventilator, intubation equipment, safety
equipment, syringe drivers, infusion pumps, and trolleys for
cannulation and arterial line insertion.
• Monitoring systems should be ready to use, and additional
disposable equipment such as ECG electrodes should be prepared in
advance. Pressure bags and transducers should be prepared and
labelled according to local guidelines.
• Computerized documentation systems for patients should be ready to
use. Smaller units may still utilize paper documentation, and if so this
should be prepared in advance.
• The patient details should provide an indication of the severity of the
patient’s condition, especially in the case of an unplanned or
emergency admission. It is likely that additional staff may be required
to assist with admission of an unstable critically ill patient, and this
should be organized prior to admission of the patient.
• Consideration should be given to providing same-sex accommodation
wherever possible.13 In situations where this is not feasible,
consideration should be given to maintaining the dignity and privacy of
the patient in mixed-sex accommodation.
Safe staffing levels within the intensive care area
With regard to staffing levels, the British Association of Critical Care

Nurses (BACCN)14 and the Royal College of Nursing (RCN)15 have
provided guiding principles. Many factors may affect staffing levels, and
it is difficult to provide an exact guide to what represents a safe number
of staff. Local policies based on the BACCN and RCN guidelines may be
used to determine safe staff numbers, as staffing is affected by a number
of locally determined factors, including the following:
• The acuity levels of these patients (i.e. the number of level 2 and
level 3 patients). Very critically ill patients may require two nurses for
periods of care.
• The design of the unit. Units where the environment and design of
the unit limit the ability to overview other patients may need increased
staffing ratios.
• Flexibility should be built in to allow for unplanned events such as
intra-hospital transfers or sudden deterioration.
The BACCN guidelines emphasize that it is essential for all patients to

have immediate access to a registered nurse with a post-registration
qualification. They suggest that level 3 patients should be nursed with a
ratio of 1:1, and that the ratio for care of level 2 patients should not
exceed 1:2. Problems with staffing ratios should be reported and acted
Page 13 of 16

date: 07 June 2021

upon by the nurse in charge of the unit, in order to maintain patient

safety.
Initial assessment of the patient
The patient’s condition will need to be assessed on admission and then

reassessed frequently until it has stabilized. In the case of emergency and
unplanned admissions it is likely that initial patient assessment will
involve several members of the critical care team so that any life-
threatening problems can be quickly identified and appropriate
management provided. At the very minimum the patient should be
assessed by the receiving nurse and a member of medical staff from the
critical care team.
The initial assessment should be thorough and systematic. Use of the

ABCDE system (see Chapter 2) ensures that life-threatening problems are
assessed and managed first, before other assessments are undertaken. It
also ensures that a quick and robust assessment of the patient is
performed.
In addition, the initial assessment should include a full physical

assessment and documentation of any areas of concern (e.g. previous
pressure damage, bruising or injury prior to admission). It is important
that consideration is also given to assessment of mental health status,
mental capacity, and any advance directives.
Assessment for previous resistant infections should be undertaken, and

local protocols followed with regard to isolation of patients transferred
from other areas within the hospital, and for referrals from another
hospital.
Alongside these assessments you may also be required to assess other

areas that will have an impact on nursing. This will be determined by
local policy, but may include:
• venous thromboembolism risk

• pressure damage risk
• nutritional assessment
• falls risk
• data collection for audit purposes
• acuity and patient scoring systems information (e.g. APACHE II,
SAPS II/III, MODS, and SOFA scores). Some of these data may be
obtained from electronic patient record systems.
All of the information that is obtained during the initial assessment should
be either documented electronically on computerized systems or
recorded on paper. This will ensure ongoing effective documented
assessment and identification of the patient’s needs. All of the
information that is obtained at the initial assessment can then be utilized
Page 14 of 16

date: 07 June 2021

to plan effective care for the patient. Assessment findings should be

communicated effectively to other members of the multidisciplinary
teams, as this has been shown to improve patient safety by ensuring
continuity of appropriate care.
Communication with the patient and their family or carers
Admission to the critical care environment can be a frightening

experience for the patient and their family or carers, and it is vital that
effective communication and psychological support are provided for all of
these individuals.
It is universally accepted that communication with the patient is vital

irrespective of whether they are conscious or unconscious on admission
to the critical care unit. If the patient is conscious and has mental
capacity, it is important that they are communicated with effectively and
actively involved in decision making about their treatment and ongoing
care. Family members may be able to provide insight into the patient’s
wishes if the patient lacks mental capacity or is unconscious.
Most critical care units provide printed booklets containing information

for patients and relatives. Such information is also available from the
Intensive Care Society16 and ICUSteps17.
Effective communication with families and carers is important, especially

in the early stages of admission, as it is unlikely that they will be able to
see the patient during the initial stages of assessment and treatment, or
until the patient’s condition has been stabilized. Effective communication
about the need to stabilize and assess the patient first is vital for helping
to establish trusting relationships with families and carers. The provision
of honest, realistic information in a form that can be easily understood is
essential both during the initial period of care and subsequently.
References
12 Critical Care Networks-National Nurse Leads (CC3N). National
Competency Framework for Adult Critical Care Nurses. CC3N, 2013.
www.cc3n.org.uk/competency-framework/4577977310
13 Department of Health. Impact Assessment of Delivering Same Sex

Accommodation. Department of Health: London, 2009.
14 Bray K et al. Standards for Nurse Staffing in Critical Care. British

Association of Critical Care Nurses (BACCN), Critical Care Networks-
National Nurse Leads, and Royal College of Nursing Critical Care Forum:
Newcastle upon Tyne, 2010.
15 Galley K and O’Riordan B. Guidance for Nurse Staffing in Critical

Care. Royal College of Nursing: London, 2007. www.rcn.org.uk/
__data/assets/pdf_file/0008/78560/001976.pdf
Page 15 of 16

date: 07 June 2021

16 Intensive Care Society. Patient Information Booklets. Intensive Care

Society: London. http://www.ics.ac.uk/icf/patients-and-relatives/
patient-information-booklets/
17 ICUSteps. Intensive care: a guide for patients and families. ICUSteps:

Milton-Keynes, 2010. http://icusteps.org/guide
Further reading
British Association of Critical Care Nurses (BACCN). www.baccn.org
Faculty of Intensive Care Medicine. http://www.ficm.ac.uk/
Gibson V and Hill K. Admitting a critically ill patient. In: Mallett J,

Albarran JW, and Richardson A (eds) Critical Care Manual of Clinical
Procedures and Competencies. John Wiley & Sons, Ltd.: Chichester, 2013.
pp. 59–62.
Intensive Care Society. www.ics.ac.uk
Royal College of Physicians. www.rcplondon.ac.uk
Page 16 of 16

date: 07 June 2021

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Admission to critical care

Oxford Handbook of Critical Care

Publisher: Oxford University Press Print Publication Date: Feb 2016

Admission to critical care

Chapter: Admission to critical care

Author(s): Heather Baid, Fiona Creed, and Jessica Hargreaves

Changes to the delivery of critical care

Changes to the delivery of critical care

The changing face of acute nursing

• an ageing population with increased levels of comorbidity

The publication of Comprehensive Critical Care: a review of adult critical

• integration of services beyond the boundaries of critical care units to

Alongside the redevelopment of critical care services, problems with the

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford

date: 07 June 2021

A seminal study by McQuillan and colleagues3 first introduced the now

McQuillan and colleagues’3 study identified that over 50% of patients

Factors related to suboptimal care—or, more recently, ‘failure to rescue’—

• lack of knowledge and lack of experience in dealing with acutely ill

A number of initiatives have been developed to improve recognition and

2 Department of Health. Comprehensive Critical Care: a review of adult

3 McQuillan P et al. Confidential inquiry into quality of care before

Preventing admissions to critical care

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford

date: 07 June 2021

A number of initiatives have been implemented to help to prevent the

• development of critical care outreach teams

Critical care outreach

The widespread development of critical care outreach services followed

• to avert admission to critical care units

The implementation of outreach has not been consistent across acute

• critical care outreach teams

Although differences exist between various configurations of critical care

Early warning scores

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford

date: 07 June 2021

parameter scores are added together and an aggregate score is then

Most recently the Royal College of Physicians has been instrumental in

This tool has been developed to provide standardization of assessment

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford

date: 07 June 2021

Table 1.1 NEWS abnormal observation values

Respiratory rate ≤8 9–11 21–24 ≥ 25

Heart rate (beats/ ≤ 40 41–50 91–110 111–130 ≥ 131

Systolic blood ≤ 90 91–100 100–110 ≥220

Temperature (°C) ≤ 35 35.1–36 38.1–39 ≥ 39.1

Oxygen saturation ≤ 91 92–93 94–95

date: 07 June 2021

Table 1.2 NEWS escalation tool

NEWS score Frequency of Clinical response

0 Minimum of 12- Continue routine NEWS

Total: 1–4 Minimum of 4- to Inform registered nurse

Total: 5 or Hourly Inform medical team

Total: 7 or Continuous Immediately inform

Medical emergency teams and emergency response teams

Medical emergency teams have been developed in many NHS trusts to

Medical emergency teams normally consist of doctors and nurses who

Although there is no significant research to support these teams yet,

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford

date: 07 June 2021

Other educational initiatives have also been developed to help to provide

Courses are either multidisciplinary or medically focused, and use a

• acute NHS trust in-house training days