Name: BHT:
Patient Observation Chart Early Warning Score
Date Day No: Wd. Wt: Kg Ht: cm Gender: M/F
DD/MM/YYYY
Target SpO2%: Other special instructions: …………………………………………………
Time
ME
WS
Sco
re
>=30 3 >=30
Respiration/min
21-29 2 21-29
12-20 0 12-20
A+B
9-11 2 9-11
<= 8 3 <= 8
>=96 0 >=96
94-95 1 94-95
91-93 2 91-93
Saturation %
<=90 3 <=90
A+B
With O2 with O2 (L/min)
(L/min)
2
>130 3 >130
2 111-130
Pulse rate /min
111-130
91-110 1 91-110
51-90 0 51-90
41-50 2 41-50
C
<=40 3 <=40
>=220 3 >=220
210 2 210
200 0 200
190 0 190
180 0 180
170 0 170
Systolic blood pressure mmHg
160 0 160
150 0 150
140 0 140
130 0 130
120 0 120
110 0 110
100 1 100
90 2 90
80 2 80
C
<=70 3 <=70
A 0 A
(Only recent onset
Consciousness
Confusion 3 Confusion
confusion gets a
/ Agitation / Agitation
V 1 V
P 2 P
score)
U 3 U
>40 3 >40
38-40 2 38-40
Temp 0C
37-37.9 0 37-37.9
35-36.9 1 35-36.9
E
<35 2 <35
TOTAL MEWS SCORE TOTAL SCORE
Blood loss (ml) Blood loss (ml)
UOP (ml) UOP (ml)
Pain score (refer pain score chart) Pain score
Escalation done (place ) Escalation done
Signature Signature
WHEN TO USE
1. Attach & Maintain the chart in following patients
i. Post operative patients
ii. Post procedural patients
iii. Deteriorating patients in a ward setting
2. Accurately Document: Name of the patient, Calendar Date, Day of the concerned event, Time of the observations and escalations done.
HOW TO USE
>=96 0
1. Observations: Document as a point/dot (●) for each parameter.
94-95 1
Place it at the center of the relevant box. 91-93 2
Connect the adjacent points to create a graph. <=90 3 3
eg: For oxygen saturation of the patient, if observation 1 is 98%, 2 is 97%, 3 is 95% and 4 is 93%, it
with O2 (L/min) 2
should be as in fig. 1.
figure 1
2. Total MEWS score
Calculate by adding each score gained by all parameters at a given time. figure 2
First hour Every 15 minutes
3. Observation frequency for postoperative patients follow fig. 2.
Next 2 hours Every 30 minutes
Next 24 hours Every 4 hours
4. Observation frequency when transferring a patient from ICU to ward Further monitoring As decided by the surgical team depending
Initiate in the ICU. At least two sets of observations should be done before discharge. on the patient’s condition
At least two sets of observations and MEWS scores should be recorded prior to the transfer.
5. Observation Frequency for deteriorating patients in the ward - Follow fig. 3.
6. Responsibility of filling the checklist: MEWS score Frequency of Clinical response
The staff nurse in the ward. monitoring
Supervised by medical officers and consultants. 0 Minimum 8 Continue routine monitoring
hourly
Total 1 – 4 Minimum Review by ward senior nurse in charge
Low risk 4-6 hourly Decide whether increased frequency of monitor-
ing and / escalation of therapy is needed.
Inform ward medical officer who should attend
figure 3 within 1 hour
3 in single parame- Minimum 1 Inform Medical officer immediately
ter hourly Urgent review by ward medical officer
Low-medium risk
Total 5 or more Minimum 1 Inform Senior Medical officer/Consultant imme-
Medium risk hourly diately
Urgent response (within 30 minutes) from a senior
medical officer/ consultant
Arrange acute bed/high dependency bed for close
monitoring
Total 7 or more Continuous moni- Emergency response: call MET/ ICU team, senior
High risk toring medical officer, inform consultant
Consider transfer to level 2 or 3 facility (HDU/ICU)
WHAT TO DO - Thresholds, Triggers and Response
(Escalation/s to be done)
Airway Threatened
Breathing All respiratory arrests
IRRESPECTIVE OF THE MEWS SCORE, IF SIGNS OF IMMEDIATE LIFE THREATENING Respiratory rate: ≤ 6 breaths per minute
CONDITIONS ARE PRESENT, CALL MET TEAM IMMEDIATELY. Respiratory rate: ≥ 36 breaths per minute
Oxygen saturation < 90%
Circulation All cardiac arrests
Pulse rate < 40 beats or >140 per minute
Follow fig. 4. Systolic blood pressure < 90 or > 180 mmHg
Neurological Sudden fall in level of consciousness
Fall in Glasgow coma scale (GCS) of > 2
Repeated or prolonged Seizures
Other If a senior staff member (N/O or MO) is seriously worried about
figure 4
any condition regarding any patient that does not fit the above cri-
teria. Eg active bleeding, chest pain
