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An '''early warning score''' (EWS) is a guide used by [[medical services]] to quickly determine the degree of illness of a patient. It is based on the six cardinal [[vital signs]] ([[respiratory rate]], [[oxygen saturation]], [[human body temperature|temperature]], [[blood pressure]], [[pulse]]/[[heart rate]], [[AVPU|AVPU response]]) and one other observation.
An '''early warning score''' (EWS) is a guide used by [[medical services]] to quickly determine the degree of illness of a patient. It is based on the [[vital signs]] ([[respiratory rate]], [[oxygen saturation]], [[human body temperature|temperature]], [[blood pressure]], [[pulse]]/[[heart rate]], [[AVPU|AVPU response]]).<ref name=NEWS2>{{cite book | editor=Williams B (ed). | title=National Early Warning Score (NEWS) 2 - Standardising the assessment of acute illness severity in the NHS
| isbn=978-1-86016-682-2 | date=2017}}</ref> Scores were developed in the late 1990s when studies showed that in-hospital deterioration and cardiac arrest was often preceded by a period of increasing abnormalities in the vital signs.


==Principles==
==The basis of an EWS==
The resulting observations are compared to a normal range to generate a single composite score, for instance based on the following diagram:
The resulting observations are compared to a normal range to generate a single composite score, for instance based on the following diagram (an early modified EWS):


{| class="wikitable"
{| class="wikitable"
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Within hospitals, the EWS is used as part of a "track-and-trigger" system whereby an increasing score produces an escalated response varying from increasing the frequency of patient's observations (for a low score) up to urgent review by a rapid response or Medical Emergency Team ([[MET call]]). Concerns by nursing staff may also be used to trigger such call, as concerns may precede changes in vital signs.<ref>{{cite journal |last1=Douw |first1=G |last2=Schoonhoven |first2=L |last3=Holwerda |first3=T |last4=Huisman-de Waal |first4=G |last5=van Zanten |first5=AR |last6=van Achterberg |first6=T |last7=van der Hoeven |first7=JG |title=Nurses' worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. |journal=Critical care (London, England) |date=20 May 2015 |volume=19 |pages=230 |doi=10.1186/s13054-015-0950-5 |pmid=25990249}}</ref>
Within hospitals, the EWS is used as part of a "track-and-trigger" system whereby an increasing score produces an escalated response varying from increasing the frequency of patient's observations (for a low score) up to urgent review by a rapid response or Medical Emergency Team ([[MET call]]). Concerns by nursing staff may also be used to trigger such call, as concerns may precede changes in vital signs.<ref>{{cite journal |last1=Douw |first1=G |last2=Schoonhoven |first2=L |last3=Holwerda |first3=T |last4=Huisman-de Waal |first4=G |last5=van Zanten |first5=AR |last6=van Achterberg |first6=T |last7=van der Hoeven |first7=JG |title=Nurses' worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. |journal=Critical care (London, England) |date=20 May 2015 |volume=19 |pages=230 |doi=10.1186/s13054-015-0950-5 |pmid=25990249}}</ref>


==The ideal EWS==
==Optimal use==
Throughout the world the EWS is based on the principle that clinical deterioration can be seen through changes in multiple physiological measurements, as well as large changes within a single variable. However, the scale is calibrated to different populations and sometimes expanded to include additional parameters, specific to different parts of the world.<ref>{{cite journal |vauthors=Morgan RJ, Williams F, Wright MM | year = 1997 | title = An early warning scoring system for detecting developing critical illness | url = | journal = Clin Intensive Care | volume = 8 | issue = | page = 100 }}</ref> The parameters scored may vary, as well as the weighting of the scores for worsening deterioration. Some systems also assign scores to other parameters including urine output, oxygen saturation, flow rate of oxygen administration and pain scores.
Throughout the world the EWS is based on the principle that clinical deterioration can be seen through changes in multiple physiological measurements, as well as large changes within a single variable. However, the scale is calibrated to different populations and sometimes expanded to include additional parameters, specific to different parts of the world.<ref name=Wright>{{cite journal |vauthors=Wright MM, Morgan RJ, Williams F | year = 1997 | title = An early warning scoring system for detecting developing critical illness | url = | journal = Clin Intensive Care | volume = 8 | issue = | page = 100 | doi=10.3109/tcic.8.2.93.110}}</ref> The parameters scored may vary, as well as the weighting of the scores for worsening deterioration. Some systems also assign scores to other parameters including urine output, oxygen saturation, flow rate of oxygen administration and pain scores.


There is a lack of consensus on what constitutes the 'ideal' early warning score system. Comparing different systems in clinical use shows variation in which parameters are scored and how those scores are assigned to differing levels of deterioration.<ref>{{cite journal | url = http://www.sciencedirect.com/science/article/pii/S0300957213000531 | doi=10.1016/j.resuscitation.2013.01.022 | volume=84 | issue=8 | title=A review of rapid response team activation parameters in New Zealand hospitals | journal=Resuscitation | pages=1040–1044 | pmid=23376581 | author=Psirides A, Hill J, Hurford S| year=2013 }}</ref> There is however some evidence that certain parameters are better at predicting which patients will die within 24 hours than others.<ref>{{cite journal | url = http://www.sciencedirect.com/science/article/pii/S030095721000242X | doi=10.1016/j.resuscitation.2010.04.014 | volume=81 | issue=8 | title=ViEWS—Towards a national early warning score for detecting adult inpatient deterioration | journal=Resuscitation | pages=932–937 | pmid=20637974 | author=Prytherch DR, Smith GB, Schmidt PE, Featherstone PI| year=2010 }}</ref> This has led to a call in several countries<ref>http://www.rcplondon.ac.uk/resources/national-early-warning-score-news</ref><ref>http://www.wellingtonicu.com/Data/NZEWS%20Proposal.pdf</ref> for the development of a national early warning score that would allow a standardised approach to assessing and responding to deteriorating patients.
There is a lack of consensus on what constitutes the 'ideal' early warning score system. Comparing different systems in clinical use shows variation in which parameters are scored and how those scores are assigned to differing levels of deterioration.<ref>{{cite journal | url = http://www.sciencedirect.com/science/article/pii/S0300957213000531 | doi=10.1016/j.resuscitation.2013.01.022 | volume=84 | issue=8 | title=A review of rapid response team activation parameters in New Zealand hospitals | journal=Resuscitation | pages=1040–1044 | pmid=23376581 | author=Psirides A, Hill J, Hurford S| year=2013 }}</ref> There is however some evidence that certain parameters are better at predicting which patients will die within 24 hours than others.<ref>{{cite journal | url = http://www.sciencedirect.com/science/article/pii/S030095721000242X | doi=10.1016/j.resuscitation.2010.04.014 | volume=81 | issue=8 | title=ViEWS—Towards a national early warning score for detecting adult inpatient deterioration | journal=Resuscitation | pages=932–937 | pmid=20637974 | author=Prytherch DR, Smith GB, Schmidt PE, Featherstone PI| year=2010 }}</ref> This has led to a call in several countries<ref>http://www.rcplondon.ac.uk/resources/national-early-warning-score-news</ref><ref>http://www.wellingtonicu.com/Data/NZEWS%20Proposal.pdf</ref> for the development of a national early warning score that would allow a standardised approach to assessing and responding to deteriorating patients.


==Variations==
==Early Warning Score variations==
A range of Early Warning Scores have been developed in response to the needs of specific patient types (e.g. PEWS for children) or to support local best practice (NEWS in the UK).
A range of Early Warning Scores have been developed in response to the needs of specific patient types (e.g. PEWS for children) or to support local best practice (NEWS in the UK).


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|NEWS & NEWS2
|NEWS & NEWS2
|Developed by the Royal College of Physicians to provide a national standard in the UK for Early Warning Scores (2012 and 2017)
|Developed by the Royal College of Physicians to provide a national standard in the UK for Early Warning Scores (2012 and 2017)
|<ref>{{Cite web|url=https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news|title=The Royal College of Physicians (RCP) has led the development of a new National Early Warning Score (NEWS) report|website=www.rcplondon.ac.uk|access-date=2016-05-10}}</ref>
|<ref>{{Cite web|url=https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news|title=The Royal College of Physicians (RCP) has led the development of a new National Early Warning Score (NEWS) report|website=www.rcplondon.ac.uk|access-date=2016-05-10}}</ref><ref name=NEWS2/>
|-
|-
|Hamilton Early Warning Score
|Hamilton Early Warning Score
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==National Early Warning Score, UK==
==National Early Warning Score, UK==
In the UK, the [[Royal College of Physicians]] has introduced a national early warning score (NEWS) to replace local or regional scores.<ref>{{cite book|author=National Early Warning Score Development and Implementation Group (NEWSDIG) |title=National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS|date=2012|publisher=Royal College of Physicians|location=London|isbn=978-1-86016-471-2}}</ref><ref name=NICECG50>{{NICE|50|Acutely ill patients in hospital|2007}}</ref><ref name=RCP>{{cite web | title=Acute care toolkit 6: the medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient | date=May 2013 | url=https://www.rcplondon.ac.uk/sites/default/files/acute_care_toolkit_6.pdf | publisher=Royal College of Physicians of London}}</ref> The NEWS score is the largest national EWS effort to date, but still remains problematic in the UK due to its lack of universal implementation ability (it has exclusion criteria) and it has yet to have its retrospective validation study published.<ref>{{cite journal |vauthors=Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI | date = Apr 2013 | title = The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death | url = | journal = Resuscitation | volume = 84 | issue = 4| pages = 465–70 | doi = 10.1016/j.resuscitation.2012.12.016 | pmid=23295778}}</ref>
In the UK, the [[Royal College of Physicians]] has introduced a national early warning score (NEWS) to replace local or regional scores.<ref>{{cite book|author=National Early Warning Score Development and Implementation Group (NEWSDIG) |title=National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS|date=2012|publisher=Royal College of Physicians|location=London|isbn=978-1-86016-471-2}}</ref><ref name=NICECG50>{{NICE|50|Acutely ill patients in hospital|2007}}</ref><ref name=RCP>{{cite web | title=Acute care toolkit 6: the medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient | date=May 2013 | url=https://www.rcplondon.ac.uk/sites/default/files/acute_care_toolkit_6.pdf | publisher=Royal College of Physicians of London}}</ref> The NEWS score is the largest national EWS effort to date, but still remains problematic in the UK due to its lack of universal implementation ability (it has exclusion criteria) and it has yet to have its retrospective validation study published.<ref>{{cite journal |vauthors=Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI | date = Apr 2013 | title = The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death | url = | journal = Resuscitation | volume = 84 | issue = 4| pages = 465–70 | doi = 10.1016/j.resuscitation.2012.12.016 | pmid=23295778}}</ref>

==History==
The first recorded EWS was developed by a team in [[James Paget Hospital]], Norfolk, United Kingdom, and presented at the May 1997 conference of the [[Intensive Care Society]].<ref name=Wright/><ref>{{cite journal |last1=Gao |first1=H |last2=McDonnell |first2=A |last3=Harrison |first3=DA |last4=Moore |first4=T |last5=Adam |first5=S |last6=Daly |first6=K |last7=Esmonde |first7=L |last8=Goldhill |first8=DR |last9=Parry |first9=GJ |last10=Rashidian |first10=A |last11=Subbe |first11=CP |last12=Harvey |first12=S |title=Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. |journal=Intensive care medicine |date=April 2007 |volume=33 |issue=4 |pages=667-79 |doi=10.1007/s00134-007-0532-3 |pmid=17318499}}</ref>


==See also==
==See also==

Revision as of 10:08, 12 August 2018

An early warning score (EWS) is a guide used by medical services to quickly determine the degree of illness of a patient. It is based on the vital signs (respiratory rate, oxygen saturation, temperature, blood pressure, pulse/heart rate, AVPU response).[1] Scores were developed in the late 1990s when studies showed that in-hospital deterioration and cardiac arrest was often preceded by a period of increasing abnormalities in the vital signs.

Principles

The resulting observations are compared to a normal range to generate a single composite score, for instance based on the following diagram (an early modified EWS):

Score 3 2 1 0 1 2 3
Respiratory rate (breaths/min) >35 31-35 21-30 9-20 <7
SpO2 (%) <85 85-89 90-92 >92
Temperature (C) >38.9 38-38.9 36-37.9 35-35.9 34-34.9 <34
Systolic BP (mmHg) >199 100-199 80-99 70-79 <70
Heart rate (bpm) >129 110-129 100-109 50-99 40-49 30-39 <30
AVPU Alert Verbal Pain Unresponsive

A score of five or more is statistically linked to increased likelihood of death or admission to an intensive care unit.[2]

Within hospitals, the EWS is used as part of a "track-and-trigger" system whereby an increasing score produces an escalated response varying from increasing the frequency of patient's observations (for a low score) up to urgent review by a rapid response or Medical Emergency Team (MET call). Concerns by nursing staff may also be used to trigger such call, as concerns may precede changes in vital signs.[3]

Optimal use

Throughout the world the EWS is based on the principle that clinical deterioration can be seen through changes in multiple physiological measurements, as well as large changes within a single variable. However, the scale is calibrated to different populations and sometimes expanded to include additional parameters, specific to different parts of the world.[4] The parameters scored may vary, as well as the weighting of the scores for worsening deterioration. Some systems also assign scores to other parameters including urine output, oxygen saturation, flow rate of oxygen administration and pain scores.

There is a lack of consensus on what constitutes the 'ideal' early warning score system. Comparing different systems in clinical use shows variation in which parameters are scored and how those scores are assigned to differing levels of deterioration.[5] There is however some evidence that certain parameters are better at predicting which patients will die within 24 hours than others.[6] This has led to a call in several countries[7][8] for the development of a national early warning score that would allow a standardised approach to assessing and responding to deteriorating patients.

Variations

A range of Early Warning Scores have been developed in response to the needs of specific patient types (e.g. PEWS for children) or to support local best practice (NEWS in the UK).

These include:

Name Acronym Description Citation
Paediatric Early Warning Score PEWS Designed to support the use of Track and Trigger with patients under 16, who have different normal ranges for observations [9]
Modified Early Obstetric Warning Score MEOWS Designed to support the use of Track and Trigger for all women receiving care from maternity services [10]
Modified Early Warning Score MEWS Modified to meet the requirements of many people in various clinical situations. [2]
National Early Warning Score NEWS & NEWS2 Developed by the Royal College of Physicians to provide a national standard in the UK for Early Warning Scores (2012 and 2017) [11][1]
Hamilton Early Warning Score HEWS Modified to identify critical events during hospitalization. [12]

National Early Warning Score, UK

In the UK, the Royal College of Physicians has introduced a national early warning score (NEWS) to replace local or regional scores.[13][14][15] The NEWS score is the largest national EWS effort to date, but still remains problematic in the UK due to its lack of universal implementation ability (it has exclusion criteria) and it has yet to have its retrospective validation study published.[16]

History

The first recorded EWS was developed by a team in James Paget Hospital, Norfolk, United Kingdom, and presented at the May 1997 conference of the Intensive Care Society.[4][17]

See also

References

  1. ^ a b Williams B (ed)., ed. (2017). National Early Warning Score (NEWS) 2 - Standardising the assessment of acute illness severity in the NHS. ISBN 978-1-86016-682-2.
  2. ^ a b Subbe C.P.; Kruger M.; Gemmel L. (2001). "Validation of a modified Early Warning Score in medical admissions". Quarterly Journal of Medicine. 94 (10): 521–6. doi:10.1093/qjmed/94.10.521.
  3. ^ Douw, G; Schoonhoven, L; Holwerda, T; Huisman-de Waal, G; van Zanten, AR; van Achterberg, T; van der Hoeven, JG (20 May 2015). "Nurses' worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review". Critical care (London, England). 19: 230. doi:10.1186/s13054-015-0950-5. PMID 25990249.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  4. ^ a b Wright MM, Morgan RJ, Williams F (1997). "An early warning scoring system for detecting developing critical illness". Clin Intensive Care. 8: 100. doi:10.3109/tcic.8.2.93.110.
  5. ^ Psirides A, Hill J, Hurford S (2013). "A review of rapid response team activation parameters in New Zealand hospitals". Resuscitation. 84 (8): 1040–1044. doi:10.1016/j.resuscitation.2013.01.022. PMID 23376581.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ Prytherch DR, Smith GB, Schmidt PE, Featherstone PI (2010). "ViEWS—Towards a national early warning score for detecting adult inpatient deterioration". Resuscitation. 81 (8): 932–937. doi:10.1016/j.resuscitation.2010.04.014. PMID 20637974.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ http://www.rcplondon.ac.uk/resources/national-early-warning-score-news
  8. ^ http://www.wellingtonicu.com/Data/NZEWS%20Proposal.pdf
  9. ^ Cadman, Jeni. "PEWS - NHS Institute for Innovation and Improvement". www.institute.nhs.uk. Retrieved 2016-05-10.
  10. ^ "MEOWS - Norfolk and Norwich University Hospital MEOWS Guidelines". www.nnuh.nhs.uk. Retrieved 2016-05-10.
  11. ^ "The Royal College of Physicians (RCP) has led the development of a new National Early Warning Score (NEWS) report". www.rcplondon.ac.uk. Retrieved 2016-05-10.
  12. ^ "The Admission Hamilton Early Warning Score (HEWS) Predicts the Risk of Critical Event during Hospitalization". {{cite web}}: Cite has empty unknown parameter: |1= (help)
  13. ^ National Early Warning Score Development and Implementation Group (NEWSDIG) (2012). National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS. London: Royal College of Physicians. ISBN 978-1-86016-471-2.
  14. ^ National Institute for Health and Clinical Excellence. Clinical guideline 50: Acutely ill patients in hospital. London, 2007.
  15. ^ "Acute care toolkit 6: the medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient" (PDF). Royal College of Physicians of London. May 2013.
  16. ^ Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI (Apr 2013). "The ability of the National Early Warning Score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death". Resuscitation. 84 (4): 465–70. doi:10.1016/j.resuscitation.2012.12.016. PMID 23295778.
  17. ^ Gao, H; McDonnell, A; Harrison, DA; Moore, T; Adam, S; Daly, K; Esmonde, L; Goldhill, DR; Parry, GJ; Rashidian, A; Subbe, CP; Harvey, S (April 2007). "Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward". Intensive care medicine. 33 (4): 667–79. doi:10.1007/s00134-007-0532-3. PMID 17318499.

External links

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