IMPACT OF EWS IN PATIENT OUTCOME

HISTORY OF EARLY WARNING SYSTEMS IN CLINICAL

PRACTICE
• In 1997 Morgan et al in the UK were the first to
develop and publish an Early Warning System composed
of five physiological parameters not only to predict
outcome, but to serve as a track and trigger system to
identify early signs of deterioration.
• The EWS that were introduced across the UK were
subsequently modified (MEWS, Modified Early Warning
Systems), and a Standardized Early Warning System
(SEWS) was developed in Scotland in 2003.
• In 2007, the National Institute for Health and
Clinical Excellence (NICE) recommended that
physiological track and trigger systems, which employ
multiple-parameter or aggregate weighted scoring
systems, should be used to monitor all adult patients
in acute hospital settings to facilitate the recognition
of patient deterioration and a timely escalation of
care.
• NICE also recommended that the chosen system
should measure heart rate, respiratory rate, systolic
blood pressure, level of consciousness, oxygen
saturation and temperature.
• Most recently, in 2010, the European
Resuscitation Council outlined the importance of
EWS by including them in the guidelines for
resuscitation and including them into the first
link in the chain of survival.
 Name Acronym Description

Designed to support the use of Track and

Paediatric Early Warning Score PEWS Trigger with patients under 16, who have
different normal ranges for observations

Designed to support the use of Track and

Modified Early Obstetric Warning
MEOWS Trigger for all women receiving care from
Score
maternity services

Modified to meet the requirements of many

Modified Early Warning Score MEWS
people in various clinical situations.

Developed by UK Royal Colleges to provide a

National Early Warning Score NEWS national standard in the UK for Early Warning
Scores
BACKGROUND :
• Critically ill patients are increasingly being nursed on
general wards, where it is reported that monitoring of
vital signs is infrequent and inadequate.
• Interpretation of signs of clinical deterioration is
poor, and responses to clinical deterioration are
inappropriate.
• Clinical and physiological deterioration, including
changes in respiratory rates, occurs six to eight hours
before cardiopulmonary arrest.
• Arrest often occurs after a period of unrecognized,
slow, and progressive physiological deterioration.
 IHCA vs OHCA
• Adult OHCAs, are mostly due to presumed cardiac
etiologies.
• It occurs unexpectedly.
• Most IHCAs are secondary to presumed acute respiratory
compromise and/or circulatory shock.
• It has predictable progressive deterioration before the
event.
N Engl J Med 2012; 367:1912-20
• Some health care professionals do not manage
patients who are deteriorating in an appropriate,
timely fashion.
• Delayed recognition that a patient is deteriorating.
• Delaying resuscitation and appropriate treatment
increases the likelihood of a patient’s organs failing due
to inadequate oxygen delivery to these tissues.
• This can lead to unexpected death, unexpected
cardiac arrest and unplanned admissions to the
intensive care unit.
• It is the key components that contribute to the lack
of appropriate patient management.
A. Absent or inaccurate observations
• Appropriate equipment not available
• Equipment malfunctioning
• Inability of staff to use appropriate equipment due
to lack of knowledge
• Inadequate time to perform observations
• Lack of understanding of why observations are
important
• General culture that observations are not important
B. Inability of staff to understand the clinical
observations recorded
• Unable to trend results and interpret their
meaning
• Lack of knowledge
C. Failure of staff to trigger timely, appropriate
response
• Absence of, or inaccurate observations
preventing correct interpretation and delaying
appropriate clinical decision making
• Inability to understand observations recorded
• Inability to develop a diagnosis
• Inability to develop a treatment plan
• Failure to escalate treatment plan if unable to
review, or failure of the patient to improve.
An example of what can go wrong
A 60-year-old man was admitted with pancreatitis and
a past medical history of hypertension
• On day three of his stay, his systolic blood pressure
fell below 90mmHg and whilst fulfilling criteria for
immediate medical review as BP EWS score = 3 the
patient was not reviewed. Over the following 24 hours,
the patient fulfilled EWS calling criteria 13 times,
however the patient’s condition was never reviewed.
The patient died 14 hours later.
• On investigation, the system issues identified
were:
- health care professionals’ failure to follow hospital
policy in activating EWS escalation plan
- inadequate documentation of observations,
particularly respiratory rate
- failure to change the management plan despite its
inadequacy
- failure to escalate the level of medical review
despite the seriousness of the situation.
Learning outcomes :
The learner will be knowledgeable in the recognition
and management of clinically deteriorating patients.
They will be able to utilise their skills and
competencies to provide supportive symptom
management until a definitive diagnosis has been
made and treatment initiated.
1. Prioritise Care, using
• Clinical judgement - apply prior and acquired
knowledge to enable early recognition and
management of the deteriorating patient.
• Decision making skills.
• Guidelines and algorithms.
• An appropriate and timely response - escalate care
as required.
2. Show Clinical Reasoning
• Recognise, interpret and act on abnormal clinical
observations.
• Understand the importance and relevance of
clinical observations and the underlying physiology.
• Interpret results of investigations.
• Recognise own limitations
3. Appropriate referral of patients
• Assess severity of illness.
• Recognise the need for specialist assistance.
• Identify the most appropriate environment for the
patient
4. Use evidence based medicine
• Utilise most recent scientific evidence agreed with
health care colleagues.
• Work within local and national guidelines and
protocols
5. Improve communication and teamworking :
• Promote the use of more focussed communication
between healthcare professionals.
• Communicate the patient status effectively with
colleagues (to the right people at the right time).
• Facilitate teamwork within the multi-disciplinary
team for enhanced patient outcomes.
• Develop and action management plans for patients in
conjunction with colleagues.
Early Warning Score
background
• An Early Warning Score (EWS) is a bedside score
and track and trigger system which nursing staff
calculate from the vital signs recorded, and aims to
indicate early signs of a patient’s deterioration.
• It is a valuable additional tool to facilitate detection
of a deteriorating patient, particularly in acute
hospital wards where patients are often quite unwell
and there may be many inexperienced staff.
• Vital signs only include Pulse, Blood Pressure,
Respiratory Rate and Temperature; however the
ViEWS takes into account other observations as well.
• The Early Warning Score (using ViEWS
parameters) considers all the patient’s recorded
observations together, not just a single observation
in isolation. It includes pulse, blood pressure,
respiratory rate, temperature, oxygen saturation,
FiO2 (inspired O2) and AVPU (Alert, response to
Voice, response to Pain, Unresponsive) score (see
Patient Observation Chart).
The EWS policy includes:
(individual hospitals must review this and adapt as
appropriate)
• Direction to nurses as to what level of doctor needs
to be notified, based on the EWS score.
• Direction for nurses on the frequency of vital sign
observation measurement once a trigger score is
reached.
EWS is beneficial as:
• It provides a point in time for communicating the
changes in a patient’s vital signs and observations and
empowers nurses and junior doctors to take
appropriate action.
• It does not replace clinical judgement when staff are
concerned about a patient (see Text Box 2)
• It assists doctors in prioritising the management of
their patients.
• Prompts more timely medical review and
treatment of patients as it has an inbuilt escalation
policy if the patient has not been reviewed within the
required time frame.
• Does not replace calling an Emergency Response
System (ERS).
NOTE: The Emergency Response System (ERS) must be
identified in each acute hospital
for daytime, out of hours, weekends etc. as appropriate to
their local hospital model.
Adult EWS Calculation

To obtain the total EWS:

1) Record a full set of vital sign observations on the
patient
2) Each individual observation is scored according to
the criteria outlined below (Table 1)
3) Total the score for each observation to achieve a
total score.
Track and Trigger procedures
• If any single parameter scores 3 or the total EWS
reaches a trigger score of 3, the activation protocol
must be initiated (Text Box 3).
• If the total EWS reaches a trigger score of 4-6 & 7,
escalated notification must be initiated (see Escalation
Protocol Flow Chart, Figure 1):
A. Increase Frequency of Vital Sign Observations
• When the total EWS score is 2, the nurse in
charge must be notified and observations
increased as per Escalation Protocol. The minimum
monitoring recommended is 6 hourly. The
frequency of observations may be increased at any
stage by the nurse.
• With improvement of the patient’s
condition, the Escalation Protocol may be
stepped down as appropriate and documented
in the management plan.
• When the total EWS score is 3, the nurse in
charge and the Team/On-call SHO must be
notified and observations increased as per
Escalation Protocol.
B. Communicate Score Appropriately
• The nurse must notify the CNM/nurse in charge,
when a patient reaches a total score of 2 (Te xt Box 4).
• The nurse must notify the nurse in charge and the
relevant medical personnel, depending on the EWS as
outlined in the Escalation Protocol flow chart (Figure 1).
Text Box 4: CNM Notification
• At the time of a patient reaching a score of 2, the
nurse must notify the CNM/Nurse in charge.
• If the patient reaches a score of 3 or above, the
nurse must always. notify the nurse in charge and
the relevant medical personnel
• Resuscitation status should be established and
documented in the patient’s notes by the primary
medical team.
National Early Warning Score Escalation Protocol
Flow Chart
Note:
 In the event of respiratory or cardiac arrest
activate the cardiac arrest system.
 If EWS score is 3 in any single parameter or AVPU
score is 3 or GCS (where this score is in use) falls > 2
points contact doctor for immediate review and
follow escalation plan.
 Escort required out of ward area: consider
expertise of personnel and equipment required for
safe transport.
Figure 1: EWS Escalation Protocol
Escort required out of ward area: consider expertise of personnel
and equipment required for safe transport.
Summary EWS Adult
 Trigger score: A score of 2 for Heart Rate ≤ 40
(Bradycardia) is a trigger point for action.
 A score of 3 in any single parameter or total EWS of
3 is the trigger point for action, with escalated
notification required at EWS of 4-6 and 7 or if the
patient is not improving.
1. EWS does NOT replace calling the cardiac arrest
team in the event of collapsed adult with suspected
no pulse and/or no breathing.
2. EWS does not replace calling the ERS as
appropriate to local hospital model.
3. EWS does not replace contacting the
registrar/consultant for immediate review of any
patient that staff are concerned about, including those
who experience a sudden fall in level of
consciousness, fall of GCS>2, repeated or prolonged
seizures or threatened airway.
• The Early Warning Score guides the Escalation
Protocol.
• The Early Warning Score does not replace clinical
judgement when staff are concerned about a patient In
the next few sections you will be taken through each
vital sign individually.
• Always remember that you must consider all the
clinical observations when assessing a patient, and not
just a single parameter in isolation.
Conclusions : A MEWS chart and training
program enhanced recording of respiratory
rate and of all parameters, and nurses’
knowledge, but not nurses’ responses to
patients who triggered the MEWS reporting
algorithm.
5 key points
1. Inpatients who experience cardiorespiratory
arrests often have abnormal vital signs in the
hours before the event.
2. Noting and escalating clinical deterioration early
can help reduce the likelihood of cardiac arrest.
3. A lack of communication between health
professionals can prevent vital information being
passed on and advice being sought.
4. There is a lack of evidence of the efficacy of
early warning systems.
5. Early warning scoring should only be used
alongside clinical judgement on patient care
• There is strong evidence that the majority of
patients who experience cardiorespiratory arrests
in hospital have abnormal vital signs in the hours
before the event (Goldhill and McGinley, 2005).
• Schein et al (1990) studied a group of 64
consecutive in-hospital cardiopulmonary arrests
and reported that 84% of patients had signs of
clinical deterioration or new complaints
documented within eight hours before the arrest.
• Franklin and Mathew (1994) supported these
findings, reporting that clinicians noted clinical
deterioration in 66% of patients included in their
study before arrest.
• In the UK, McQuillan et al (1998) reviewed the
quality of care in two groups of 50 consecutive
patients before admission to ICU. They found
evidence of suboptimal care, often defined as a
failure to recognise clinical signs of deterioration
or failure to act on these signs.
• A systematic review found limited evidence of the
validity, reliability and utility of track-and-trigger
systems and suggested they should only be used in
combination with clinical judgement (Gao et al, 2007).
• This is supported by Jansen and Cuthbertson (2010)
who claim there is poor evidence behind the use of
EWS systems and further research is needed to
validate their use.
• However, they also suggest EWS can promote good
practice by reinforcing the need for regular
physiological observations.
• The Critical Care Stakeholder Forum (2005) identified
three key problems that could cause delays in
identification and referral:
1. Low standards of documentation and observations
on general wards;
2. Poor knowledge of critical illness and its
presentation;
3. Suboptimal treatment of at-risk patients due to
inadequate skills and knowledge, and organisational
failings.
• However, Andrew and Waterman (2001) argued that
EWS can be used as a tool to overcome these clinical and
communication barriers, as the tool gives nurses the
opportunity to present their concerns as evidence to
medical staff.
• A review by Smith et al (2008) identified 72 EWS or
track-and-trigger systems, highlighting a point raised by
Subbe (2010) that the many adaptations of EWS
questions makes their validity questionable. In an
attempt to standardise practice, the Royal College of
Physicians (2012) published a report recommending the
use of a national early warning score (NEWS) in the UK.
Algoritma Early Warning Score
 Gambar 1 menunjukkan skor dari MEWS. Skor ini
dipakai dalam sistem MEWS yang telah dimodifikasi oleh
Gardner-Thorpe et.al., yang memungkinkan skrining
awal untuk pasien yang membutuhkan perawatan
intensif karena penyakit/pembedahan.(5)
 Tekanan darah, denyut nadi, laju pernapasan, suhu
tubuh, kesadaran, dan kekhawatiran tentang kondisi
pasien masing-masing diberi skor 0-3, dan jumlah dari
nilai dihitung.
 Sebuah skor yang lebih tinggi menunjukkan
peningkatan keparahan.(6)
 Parameter MEWS adalah panduan untuk tenaga
medis untuk lebih mengenali kondisi pasien sebelum
terjadinya perburukan kondisi klinis dan untuk
memungkinkan mereka untuk memberikan intervensi
dini.
 Selain itu, karena tanda-tanda vital yang digunakan
dalam sistem untuk deteksi, kemampuan dari tenaga
medis tidak mempengaruhi hasil.
 Drower et al. melaporkan bahwa kejadian serangan
jantung per 1.000 pasien secara signifikan menurun
dari 4,67 pada tahun 2009-2010 menjadi 2,91 pada
tahun 2010-2011 setelah pengenalan sistem MEWS
pada 600 rumah sakit pendidikan di Selandia Baru.(3)
Tabel 1. Persentase Henti Jantung berdasarkanskor Modified
Early Warning Scoredi Rumah Sakit Chubu Tokushukai, Jepang
Tahun 2013.

Skor MEWS Insiden Henti Jantung

6 1/556 (0.18%)

7 4/286 (1.40%)

8 2/114 (1.75%)

≥9 2/56 (3.57%)