Early warning score

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An early warning score (MEWS) is a guide used by hospital nursing & medical staff as well as emergency 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 resulting observations are compared to a normal range to generate a single composite score, for instance based on the following diagram:

Score 3 2 1 0 1 2 3
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
Temperature (°C) <35 35.0-38.4 >38.5
AVPU A V P U

A score of five or more is statistically linked to increased likelihood of death or admission to an intensive care unit.[1]

Different EWS systems are in use worldwide; either the parameters scored vary or the weighting of the scores for worsening deterioration are changed. 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.[2] There is however some evidence that certain parameters are better at predicting which patients will die within 24 hours than others.[3] This has led to a call in several countries[4][5] for the development of a national early warning score that would allow a standardised approach to assessing and responding to deteriorating patients.

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).

Some examples of MEWS systems currently in use are shown below.

Leeds Teaching Hospitals Trust (LTHT), England 2011[edit]

(accurate as of February 2011)[6]

Score 3 2 1 0 1 2 3
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
AVPU New Confusion Alert Voice Pain Unconscious
Urine Output (mls) <80 80-119 120-200 >200 >800
Pain Score Severe Moderate Mild None

Wellington Hospital, New Zealand 2012[edit]

(accurate as of January 2012)[7]

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.

The Early Warning Score matrix for Wellington Hospital, Wellington, New Zealand.
A coloured Early Warning Score matrix.

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[edit]

In the UK, the Royal College of Physicians has introduced a national early warning score (NEWS) to replace local or regional scores.[8][9][10]

References[edit]

  1. ^ 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
  2. ^ http://www.sciencedirect.com/science/article/pii/S0300957213000531
  3. ^ http://www.sciencedirect.com/science/article/pii/S030095721000242X
  4. ^ http://www.rcplondon.ac.uk/resources/national-early-warning-score-news
  5. ^ http://www.wellingtonicu.com/Data/NZEWS%20Proposal.pdf
  6. ^ Brown, H. (2010). Graded Response Observation Chart (Leeds Teaching Hospitals Trust - Revision date: November 2012)
  7. ^ http://www.wellingtonicu.com/AboutUs/Services/EWS/
  8. ^ 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. 
  9. ^ National Institute for Health and Clinical Excellence. Clinical guideline 50: Acutely ill patients in hospital. London, 2007.
  10. ^ "Acute care toolkit 6: the medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient". Royal College of Physicians of London. May 2013.