Early warning score
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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 data derived from four physiological readings (systolic blood pressure, heart rate, respiratory rate, body temperature) and one observation (level of consciousness, AVPU).
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:
|Systolic BP||<45%||30%||15% down||Normal for patient||15% up||30%||>45%|
|Heart rate (BPM)||—||<40||41-50||51-100||101-110||111-129||>130|
|Respiratory rate (RPM)||—||<9||—||9-14||15-20||21-29||>30|
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).
The ideal EWS
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. 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. There is however some evidence that certain parameters are better at predicting which patients will die within 24 hours than others. This has led to a call in several countries for the development of a national early warning score that would allow a standardised approach to assessing and responding to deteriorating patients.
Leeds Teaching Hospitals Trust (LTHT), England 2011
(accurate as of February 2011)
|Systolic BP||<45%||<30%||15% down||Normal for patient||15% up||30% up||>45%|
|Heart rate (BPM)||<30||<40||41-50||51-100||101-110||111-130||>130|
|Respiratory rate (RPM)||<8||—||8-11||12-20||21-25||26-30||>30|
|Oxygen Saturations (%)||<85||>85||>90||>95||—||—||—|
|Respiratory Support||CPAP BiPAP||>60%||O2||Nil||—||—||—|
|Urine Output (mls)||<80||80-119||120-200||>200||>800||—||—|
Wellington Hospital, New Zealand 2012
(accurate as of January 2012)
This matrix links the MEWS with a coloured band that corresponds to that on the observation chart. This not only provides visual cues to deterioration but also makes it easier to assign a score once the colours are learned.
This system also demonstrates 'single parameter' triggering whereby an extreme deterioration results in a mandatory MET call which ensures immediate attendance by a Medical Emergency Team to the bedside of the sickest patients.
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. 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.
Sundsvall Regional Hospital, Sweden
|Respiratory rate||< 9||9-14||15-20||21-29||≥ 30|
|Pulse||≤ 40||41-50||51-100||101-110||111-129||≥ 130|
|Systolic blood pressure||≤ 70||71-80||81-100||101-199||≥ 200|
|Temperature (°C)||≤ 35||35.1-36||36.1-38||38.1-38.5||≥ 38.6|
|AVPU||New-onset confusion||Alert||Reacts to voice||Reacts to pain||Unresponsive|
Following are guidelines for re-estimating MEWS:
|0||Withing 24 hours|
|1||Withing 8-12 hours|
|2||Withing 4-8 hours|
|3||Withing 1-2 hours|
|≥4||Contact with mobile intensive care team|
- Subbe C.P., Kruger M., Gemmel L. - "Validation of a modified Early Warning Score in medical admissions." Quarterly Journal of Medicine 2001; 94; 521-6
- Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997; 8: 100.
- Brown, H. (2010). Graded Response Observation Chart (Leeds Teaching Hospitals Trust - Revision date: November 2012)
- 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.
- National Institute for Health and Clinical Excellence. Clinical guideline 50: Acutely ill patients in hospital. London, 2007.
- "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.
- Smith GB, Prytherch DR, Meredith P, Schmidt PE, Featherstone PI.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. 2013 Apr;84(4):465-70. doi: 10.1016/j.resuscitation.2012.12.016. Epub 2013 Jan 4.
- Modified Early Warning Score MEWS, document by The Management Team for the County Hospital of Sundsvall-Härnösand. 2011-02-07