mysafety insight
Automated Early Warning-
Score (EWS) System
Clinical Information Leaflet
mysafety insight
Automated EWS System
Early Recognition Of Deterioration
To Improve Clinical Outcomes And Patient Safety
Can patient deterioration
be anticipated?
Studies have shown that in a large number of
patients admitted to critical care depart-
ments, life -threatening changes were
observed and documented up to 8 hours
60% 70%
before the admission (Figure 1) [1,2,3] . These
ICU patients Cardiac patients
observations and decisions arising from such
Percentage of patients
early manifestation could improve care and showing signs of early deterioration
resuscitation outcomes, because most further up to 8 hours
deteriorations and even death can be before the admission/episode
prevented with early intervention (Figure 2). Figure 1. Deterioration could be anticipated earlier
Adverse events (AE) in hospitalised patients
Hospitalised patients who develop an AE
Mortality after AE
Percentage of deaths that could be prevented
10%
5-8%
50%
Figure 2. Incidence of in-hospital adverse events, mortality rate after AE, and the percentage of preventability [4,5,6,7,8]
Why does early deterioration some-
times go undetected?
However, there are numerous reports that the most common incident type was a failure
indicate there is a high risk of missing patient to recognise or act on deteriorations (23%).
deterioration episodes that develop in unex-
pected adverse events. One of these docu- One of the reasons why patient deterioration
ments is the “Patient-Safety-Related Hospital may not be detected is the nurse-to-patient
Deaths in England: Thematic Analysis of Inci- ratio and the subsequent frequency of vital
dents Repor ted to a National Database, sign monitoring; which decreases from
2010–2012” [9]. It was reported that of all the higher to lower acuity care units. To confirm
reviewed hospital deaths on the document, this hypothesis, a prospective defined
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mysafety insight
Automated EWS System
analysis of the UK National Cardiac Arrest Audit (NCAA), collected data from 144 acute hospitals
relating to 23,554 patients over the age of 16, showing that most in-hospital cardiac arrests
occurred in General Wards (56.6%) and not the conventional acute care units such as ICU (5.2%)
or CCU (10.4%) (Figure 3) [10].
General Ward Emergency CCU Other departments
56.6% 18.2% 10.4% 9.6%
Figure 3. Location of cardiac arrests for 23,554 in-hospital patients
Looking For A Systemic Approach To Identify
Early Deterioration
Early recognition of patient deterioration
to reduce sudden adverse events (SAE)
Research figures suggest that failing to identi- physiological parameters [15].
fy early deterioration can increase the risk of
Protocols used for EWS systems
mortality. For example, Cardoso et al. report-
ed that each hour of delay in the admission
of a patient to the ICU was associated with a
EWS 90‘s EWS 1999 EWS 2012 EWS 2017
1.5% increased risk of ICU death [11]. Therefore,
timely recognition of patients with deteriorat-
ing acute illness and providing prompt man- Several different · Respiratory rate MEWS + MEWS +
physiological · Systolic blood · Oxygen saturation · SpO₂ scale 1
agement can be of great influence in improv- parameters pressure · Any supplemental and 2
· Pulse rate oxygen · Air or Oxygen
ing clinical outcomes. It can reduce the need · Level of
consciousness
to transfer these patients to higher acuity · Temperature
units like ICU, decrease the length of a hospi- Figure 4. The development of typical EWS protocols
tal stay, and reduce the costs [12,13].
For example, in the UK, several reports from
In-hospital patient deterioration is often the National Institute for Health and Clinical
preceded by a period of abnormalities in vital Excellence (NICE) and the Royal College of
signs, for example, changes in physiological Physicians, have advocated the use of the
parameters like pulse, blood pressure, respira- two most popular EWS systems worldwide,
tory rate and temperature [14]. Based on this Modified Early Warning Score (MEWS) and
premise, in the late 90’ s several studies were National Early Warning Score (NEWS). NEWS2
able to develop scores to anticipate these is the latest version of NEWS, updated in
situations, and as a result, Early Warning 2017. All these protocols advocate a system
Scores (EWS) were created to determine the to standardise the assessment and response
degree of patients’ illness based on their to acute illness (Figure 5).
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Automated EWS System
However, throughout the world, EWS departs • Pulse rate: tachycardia may indicate circula-
from the principle that clinical deterioration tory compromise.
can be seen through changes in multiple
• Level of consciousness: Alert: a fully awake
physiological measurements. These scales are
patient; Voice: the patient makes a response
calibrated to different populations and the
to voice; Pain: the patient delivers a response
scored parameters may vary. Until recently
to a pain stimulus; Unresponsive: the patient
there has been a lack of consensus regarding
does not give a response to voice or pain.
the ideal EWS protocol, but there is evidence
that certain parameters are better than others • Temperature: a temperature that is too high
to identify early deterioration [16]. or too low is a sensitive indicator of acute
Listed below is a description of the physio- illness, especially infection.
logical parameters included in most • Oxygen saturation: oxygen saturation is an
EWS systems: impor tant parameter for the integrated
• Respiratory rate: respiratory rate is an assessment of pulmonary and cardiac func-
important indicator of potential respiratory tion. Routine monitoring by pulse oximetry is
dysfunction. recommended (NEWS and NEWS2).
• Systolic blood pressure: high systolic blood • Patient on room air or supplemental oxygen:
pressure may indicate cardiovascular disease, whether the patient is on oxygen support
while low systolic blood pressure may (NEWS and NEWS2).
indicate circulatory compromise.
National Early Warning Score 2 (NEWS2)
Physiological
3 2 1 0 1 2 3
parameters
Respiratory rate (permin) ≤8 - 9-11 12-20 - 21-24 ≥25
SpO scale 1(%) ≤91 92-93 94-95 ≥96 - - -
SpO scale 2(%) ≤83 84-85 86-87 88-92/ ≥93 on air 93-94(on oxygen) 95-96(on oxygen) ≥97 on oxygen
Air or oxygen? - Oxygen - Air - - -
Systolic BP (mmHg) ≤90 91-100 101-110 111-219 - - ≥220
Pulse rate (per min) ≤40 - 41-50 51-90 91-110 111-130 ≥131
Level of consciousness - - - A - - C,V,P or U
Temperature (°C) ≤35.0 - 35.1-36.0 36.1-38.0 38.1-39.0 ≥39.1 -
A=Alert C=New confusion (delirium) V=Response to verbal stimulation P=Response to painful stimulation U=Unresponsive
NEWS2 score Clinicalrisk Frequency of monitoring Clinical response
Total score 0 Minimum 12 hourly · Continue routine NEWS monitoring
· Inform registered nurse who must assess the patient
Total score 1-4 Low Minimum 4-6 hourly · Registered nurse decides whether increased frequency of
monitoring and⁄or escalation of care is required
· Registered nurse to inform medical team caring for the patient who will review
3 in a single parameter Low-medium Minimum 1 hourly
and decide whether escalation of care is necessary
· Registered nurse to immediately inform the medical team caring for the patient
Total 5 or more: · Registered nurse to request urgent assessment by a clinician or team
Urgent response threshold Medium Minimum 1 hourly
with core competencies in the care of acutely ill patients
· Provide clinical care in an environment with monitoring facilities
· Registered nurse to immediately inform the medical team caring for the
patientthis should be at least at specialist registrar level
· Emergency assessment by a team with critical care competencies including
Total 7 or more: Emergency High Continuous monitoring practition(s) with advanced airway management skills
response threshold of vital signs
· Consider transfer of care to a level 2 or 3 clinical care facility ie higher-
dependency unit or ICU
· Clinical care in an environment with monitoring facilities
Figure 5. An example of how an EWS system works (NEWS2)
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mysafety insight
Automated EWS System
Automated EWS And Its Application
Along The Clinical Pathway To Improve Outcomes
Recommending EWS
It is recommended to use EWS during initial
prehospital and/or hospital assessment of a
patient throughout the patient’ s hospital stay
[17]
. However, EWS should only be used as an
aid to clinical decision making rather than a
substitute for the prognosis of critically ill
patients. The overall performance of the EWS
system is not solely dependent on the scor- Figure 6. Typical scenarios where EWS can be helpful
ing system but also the organization of the
response [18]. Successful implementation of an Automated systems to improve
EWS in the hospital must go hand in hand workflow
with proper education of staff and increasing
awareness of the necessity of structural Automatisation of EWS into the vital signs
patient monitoring. This will eventually lead monitoring system has decreased the time
to a change in the mindset of healthcare pro- required for vital sign measurement and
viders to collaborate as a team, thereby lead- recording, an improvement in the proportion
ing to a better organization of patient care. of rapid-response-team-calls triggered by
Every score should be used as an adjunct to respiratory criteria, and an increase in the
the clinical judgment of the doctor [15]. survival rate of patients receiving rapid-re-
sponse-team-calls [19].
Without EWS
Stable patients Nurses manually find Sudden deterioration meets
abnormal vital signs Unplanned ICU admission
the RRT call criteria
With automated EWS
ICU admission
The patient
Stable patients EWS identifies EWS detects the EWS alert triggers MRP status is
abnormal vital continuous deterioration, call or RRT call, helping stabilized by
signs, notifying increasing round with the clinical early
bedside nurses for frequency and notifying decision for ICU transfer interventions
regular check the Ward Team Leader
Figure 7. An example of how automated EWS systems
could help with workflow
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mysafety insight
Automated EWS System
Fast Intervention With Mindray Automated EWS, Smart
Alarming, And Intuitive Visuals
Flexible and configurable protocols Intuitive visuals and a comprehensive
graphic display
Mindray’s EWS will provide the standard Mindray’s Intuitive Visuals system shows all
MEWS, NEWS, and NEWS2, but will also allow relevant information in one place, with data
users to create and save customised scoring integrated into the patient monitor’s main
protocols. To better satisfy patient needs, the screen. With a single tap of the finger, the
individual parameter scoring (IPS) places full EWS panel will appear or disappear and can
control of all parameters and limits in the display short or long trends. Even when the
clinicians’ hands. EWS panel is not shown directly on the patient
monitor main screen, a small graphic will
Automated EWS and Smart Alarming show the current EWS status as well as infor-
Early warning scores are used to identify the mation from the other patient parameters.
patients at risk. With Mindray’ s automated
EWS, a patient’ s vital signs are automatically
measured and the EWS is calculated regularly
or linked to certain conditions. Auto calcula-
tion of a new score can be triggered by each
or all the three following events: preset time
interval or interval according to the last EWS
score, every new NIBP, or a vital sign alarm
(Figure 8). The interval can be set by the user Figure 9. Clinical response according to different scores
in a time range (from 5 minutes to 24 hours)
• Clinical response according to different
or according to the patient’ s last EWS score
scores empowers staff to make more
result. Once a deterioration is detected, the
informed decisions and is available with a
patient monitor will start alarming based on
simple finger tap.
predefined settings to inform the responsible
staff about the change in patient condition at
an early stage.
Interval
NIBP
Auto
Alarm
Scoring
Auto Scoring Interval,Alarm,NIBP
Interval By Score
Score Interval
0 4 hrs
1~3 2 hrs
Figure 10. EWS trends with detailed information
4~6 1 hr • In this time scale example, users can see the
7~14 30 min patient’s EWS development or examine both
Figure 8. Auto calculation of a new socre can be linked to comprehensive and mini trend views for
certain conditions further patient insights. 05
mysafety insight
Automated EWS System
Aiming to create safer patient environments, Mindray incorporates automated early
warning scoring notification systems in a wide range of patient monitors, from low to
high acuity. By including this EWS system, Mindray products contribute to safer and
more efficient patient management by anticipating potential complications and
improving workflows.
References:
1. Hillman, K.M., et al., Duration of life-threatening antecedents 11. Cardoso, L.T., et al., Impact of delayed admission to inten-
sive care units on mortality of critically ill patients: a cohort
prior to intensive care admission. Intensive Care Med, 2002. 28
study. Crit Care, 2011. 15(1): p. R28.
(11): p. 1629-34.
12. Brown, H., et al., Continuous monitoring in an inpatient
2. Schein, R.M., et al., Clinical antecedents to in-hospital cardio- medical-surgical unit: a controlled clinical trial. Am J Med,
pulmonary arrest. Chest, 1990. 98(6): p. 1388-92. 2014. 127(3): p. 226-32.
3. Goldhill, D.R., S.A. White, and A. Sumner, Physiological values 13. Subbe, C.P., B. Duller, and R. Bellomo, Effect of an automat-
and procedures in the 24 h before ICU admission from the ed notification system for deteriorating ward patients on
ward. Anaesthesia, 1999. 54(6): p. 529-34. clinical outcomes. Crit Care, 2017. 21(1): p. 52.
4. Al-Qahtani, S. and H.M. Al-Dorzi, Rapid response systems in 14. Gerry, S., et al., Early warning scores for detecting deterio-
acute hospital care. Ann Thorac Med, 2010. 5(1): p. 1-4. ration in adult hospital patients: a systematic review protocol.
BMJ Open, 2017. 7(12): p. e019268.
5. Kohn, L.T., J. Corrigan, and M.S. Donaldson, To err is human:
building a safer health system. Vol. 6. 2000: National academy 15. Alam, N., et al., The impact of the use of the Early Warning
press Washington, DC. Score (EWS) on patient outcomes: a systematic review. Resus-
citation, 2014. 85(5): p. 587-94.
6. Baker, G.R., et al., The Canadian Adverse Events Study: the
incidence of adverse events among hospital patients in 16. Prytherch, D.R., et al., ViEWS--Towards a national early
Canada. warning score for detecting adult inpatient deterioration.
Resuscitation, 2010. 81(8): p. 932-7.
7. Wilson, R.M., et al., The Quality in Australian Health Care
Study. Med J Aust, 1995. 163(9): p. 458-71. 17. Royal College of Physicians. National early warning score
(NEWS): standardizing the assessment of acute-illness severity
8. McQuillan, P., et al., Confidential inquiry into quality of care in the NHS. London: RCP, 2012. 2012.
before admission to intensive care. Bmj, 1998. 316(7148): p.
1853-8. 18. Patterson, C., et al., Early warning systems in the UK:
variation in content and implementation strategy has implica-
9. Donaldson, L.J., S.S. Panesar, and A. Darzi, Patient-safety-re- tions for a NHS early warning system. Clin Med (Lond), 2011.
lated hospital deaths in England: thematic analysis of 11(5): p. 424-7.
incidents reported to a national database, 2010-2012. PLoS
Med, 2014. 11(6): p. e1001667. 19. Bellomo, R., et al., A controlled trial of electronic automat-
ed advisory vital signs monitoring in general hospital wards.
10. Nolan, J.P., et al., Incidence and outcome of in-hospital Crit Care Med, 2012. 40(8): p. 2349-61.
cardiac arrest in the United Kingdom National Cardiac Arrest
Audit. Resuscitation, 2014. 85(8): p. 987-92.
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