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Introduction

The close monitoring of patients physiological parameters is the cornerstone in the early detection of critical illness. However research has demonstrated that early changes in patient observations are often not detected or communicated to the appropriate personnel leading to a delay in intervention .1,2,3,4 The Early Warning Scoring System (EWS) was developed by Morgan et al in 1997 5 with the aim of providing a simple scoring system which could be readily applied by nurses and doctors to help identify patients developing critical illness. The EWS can be described as a aggregate weighted scoring system with six physiological parameters (Respiratory Rate, Oxygen Saturations, Heart Rate, Systolic Blood Pressure, Temperature and Neurological Status) scored between 0 - 3 with a aggregate score of three or more triggering the start of the protocol. The use of such early warning tools has be recommended by the Critical Care Outreach report published in 2003 6

and later advocated in the National Institute in Clinical Excellence (NICE) Clinical guidance 50 “Acutely ill hospital patient”7 suggesting these tools enhance equity in care by ensuring timely recognition of all patients with potential or established critical illness and their treatment by individuals with appropriate skills, knowledge and experience to treat the patient effectively. Within Central Manchester University NHS Foundation Trust (CMFT) the EWS has been introduced in acute areas since 2000 and is linked to a protocol to ensure patients are assessed and treated by suitably experienced personnel in a timely fashion. Purpose The purpose of the EWS policy is to ensure that an accurate assessment of a patients clinical parameters, followed by an accurate calculation and documentation of the EWS on the observation chart and appropriate intervention utilising the protocol. This will:

• Minimise risk

• Improve patient safety and experience

• Ensure appropriate personnel respond dependant on the patients level of risk of deterioration

• To ensure complete and accurate communication and documentation of changes in clinical parameters and interventions on the ward, department or unit

• Ensure the accurate recording of and response to EWS changes is of the standard required.

Summary of EWS Policy for NHSP Staff For full version see CMFT Intranet

Contact Sister Donna Egan –outreach coordinator bleep 8742 Tel: 0161 276 8742

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Exclusions

An EWS should be completed with each set of clinical observations except those patients who have been commenced on the care of the dying pathway. The protocol is split into three categories; low, medium and high risk of deterioration each defined by the EWS calculated following the observations. The bedside observation response and alerting system is being implemented across the Trust this will automatically alert the correct personnel as per the EWS policy, manual alerting can also occur as is deemed appropriate. The patientrack policy will have all details and actions for the use of this system (see the intranet for the latest policy). The Measurement of Patient Parameters

• Patient parameters / observations should be measured by an appropriately trained and competent member of staff as per the Observation policy.

• All chart entries should be clear, legible, written in black pen and the time and date of the observations clearly documented on the Trust observation chart or agreed local documentation or inputted into patientrack system. (See the Trust observation policy)

• A full set of observations should always be recorded, to include pulse rate, respiratory rate, blood pressure, temperature and neurological status and oxygen saturation. If an observation is unrecordable or undetectable e.g. oxygen saturations (SaO2) or blood pressure (BP), escalate to the nurse in charge to assess the patient, refer to medical team if required. This is an automatic score of 3 unless assessed and registrar has altered parameters

• The observations should be initialled on the observation chart if used, by the person undertaking the observations.

Frequency of observations – see observation policy

• The frequency of observations should be determined by; a registered nurse in charge of the shift, senior doctor (Registrar or Consultant) and should be clearly documented on the observation chart; unless a patient has a EWS of ≥ 3 when observations will be recorded hourly as a minimum.

• All patients should have a minimum of 12 hourly observations, with the exceptions as per below.

• All acute (non – elective) admissions should have a minimum of 4 hourly observations.

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• Within the Emergency Department (ED) frequency is as per local ED EWS policy.

• All Post operative patients should have frequency as below unless medical staff document alternative request; 30 minutes for 2 hours Hourly for 2 hours As patient need dictates minimum 4 hourly

• When a patient is on the Liverpool care pathway the observations may be stopped.

• If a patient is a delayed discharge home and medically fit their observations may reduce to daily.

• Observation frequency can be reduced by a senior team member; consultant, registrar or registered nurse in charge of shift (Trust member) only and should be documented on the observation chart and in the medical notes.

Calculation of the Early Warning Score

• The EWS should be calculated for every set of observations.

• The total EWS and individual parameters scores should be documented for every set of observations on the patients observation chart. Where applicable with patientrack, these scores will be automatically calculated as observations are input into the system.

The EWS parameters:

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Appropriate intervention utilising the Protocol

• An EWS of three or more triggers the start of the EWS flowchart which clearly highlights the steps to be taken. (see flowchart)

• When a patient has an EWS trigger, observations should be undertaken hourly as a minimum, until the EWS is reduced < 3

Low Risk category: Following the first trigger of an EWS = 3, the primary nurse responder must be informed. They should attend the patient within an hour and assess the patient and institute an appropriate intervention. If the intervention does not reduce the EWS within an hour the next referral should be made the primary medical responder and primary nurse responder.

• If a patient has triggered 4 times at an EWS = 3, then an arterial blood gas should be considered. If the EWS does not reduce following intervention the patient should be referred to the primary nurse responder and the secondary responder within the hour.

• Following a full assessment, which may include an arterial blood gas(ABG) the parameters for the patient can be discussed with the senior medical team and it may be deemed appropriate to alter the parameters.

Medium Risk category: If a patient triggers an EWS = 4 or 5, or an EWS = 3 for a fifth time, the primary nurse responder and the secondary responder must be informed and should attend within one hour.

• If the patient triggers EWS = 4 or 5 for a second time, or has an EWS = 3 for a sixth time, then the doctor should re-attend within the hour and an arterial blood gas should be taken and further assessment and treatment implemented.

Exemption- An ABG will only be taken in thrombocytopenic haematology patients with platelets < 80 that demonstrate clear signs of respiratory decompensation (respiratory rate ≥30 or oxygen requirement≥ 50% to maintain target saturations). If the trigger is due to infection without respiratory decompensation a venous blood gas should be taken.

• If the patient triggers EWS = 4 or 5 for a forth time or EWS = 3 for a eighth time the patient should be directed to the high risk category.

High Risk category: If the EWS ≥ 6 or a patient triggers EWS = 4 or 5 for a fourth time or a static EWS =3 for the eighth time, the primary nurse responder should be contacted and a ST3 or above from the parent team and the critical care medical team should be contacted directly. If the EWS ≥ 6 for a second time, EWS = 4 or 5 for a fifth time, EWS= 3 for a ninth time the critical care medical team (Bleep 4716). The teams should both attend within 30 minutes.

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• If the parent team (registrar or consultant) has made the decision not to escalate to critical care they must document this in the medical notes with treatment plan and /or adapted parameters.

• At any time, in the light of actual or anticipated severe deterioration or there is cause for concern, consider immediate direction to high risk category, where a senior doctor and the critical care medical team must be contacted immediately.

• All EWS triggers must be documented in both medical and nursing notes.

• For the first EWS ≥ 6 an ABG should be taken, for others in the high risk group an ABG should be considered to assess response to interventions.

Exemption- An ABG will only be taken in thrombocytopenic haematology patients with platelets < 80 that demonstrate clear signs of respiratory decompensation. (Respiratory rate ≥30 or oxygen requirement≥ 50% to maintain target saturations)If the trigger is due to infection without respiratory decompensation a venous blood gas should be taken.

• For subsequent triggers ≥6 the response should be as above unless otherwise stated and documented by the parent team.

The EWS Response flow chart Daytime 07:31-20:59 hrs:

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EWS Flow Chart Night- 21:00-07:30 hrs

Alteration of EWS parameters

• If a patient has a chronic alteration to one or more of the measured parameters E.g. elevated heart rate due to chronic atrial fibrillation or Type 2 respiratory failure where the patients usual SaO2 is less than 94%. It may be appropriate to alter the scoring criteria for that parameter.

• Scoring criteria may only be changed following a full medical assessment which may include an ABG, by a senior doctor.

• The triggering threshold e.g. EWS ≥3 should never be altered.

• If EWS scoring parameters are altered it must be documented in the patient’s medical and nursing notes and the new scoring criteria recorded on the observation chart or bedside observation recognition alerting system (BORAS) system with the clinician altering the parameters printing and signing their name. They must also document the date and time of alteration on the observation chart. A review date for the new parameters may also be documented.

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Transfer of patient with early warning scores of ≥3

• If a patient requires transfer to another clinical area and has an EWS of ≥3 a doctor (ST1 or above) must assess the patient. This assessment should determine if the patient is medically fit for transfer or if intervention is required to stabilise the patient prior to transfer. See Trust transfer policy (latest version on intranet)

• The assessment and decision to transfer should be documented in the patient medical and nursing notes.

• The Trust intra-hospital transfer form should be used. (See Trust transfer policy available on the intranet)

Communication

• Ensure concise and effective communication when referring patients to senior members of the team or other team members.

• Use the SBAR tool for communication to maintain standards and effective communication.

S o Inform the nurse in charge Perform relevant nursing intervention

Situation

o Your name is………………………………………………………

o Patients name is ……………………………………………………

o Age……………….

o Sex Male Female

o Bed Number ……………………………Ward…..……………………

o Why you are calling …………………………………………

……………………………………………………………………………

B Background

o Reason for admission………………………………………………….

Recent Surgery if yes ………………………………..….

A Assessment Having assessed the patient

EWS= …………

A. Airway is ……………………………………………

Oxygen is at …………………………….via a …………………………...

B. RR is ……………………………………..Rhythm………………………...

Depth…………………………………......Symmetry………………………

Colour ……………………………………Saturation ……………………..

C. Pulse (Reg/ Irreg)……………………….BP………………………………

Temperature……………………………..CRT…………………………….

Urine Output in the last hour……….....Last 4 hours………………..….

D. AVPU score………………………………

Any changes to mental state………………………………………………

Blood Glucose…………………………..Pupils size / reaction………….

Pain Score; Movement…………………Rest…………………………….

E. Head to toe examination; Patient has ……………………………………

Blood loss…………………………………Abnormal swelling……………

Loss from drains/ wounds……………….

R Recommendation

o What do you want from person calling? ………….……………….

o How urgent is it? …………………………………….

o What can be done in the meantime………………..……………….

………………………………………………………………………….….

What time will Medical staff attend? ……………………………………….

Time of review …………………………………………………………

o Ensure documentation in kardex

o Time of Call

o Person Making call and name of medical staff spoken to

o Relevant intervention

Assessment and Plan

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• Ensure all communication to the team including Safety Huddles, addresses EWS variance and clinical concerns at shift changeover.

• Each time a patient triggers ≥3 or there is cause for clinical concern it should be documented in the nursing and medical records. This should include assessment and management plan. The exception is the initial trigger of 3 as this will be a nurse response and the minimum requirement would be in the nursing documentation.

Trust Observation chart

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Early Warning Score Policy for Adult Patients in the A&E Department

The Early Warning Score

Use of the EWS can be divided into three areas. These are: the measurement of patient parameters, calculation of the EWS and appropriate intervention utilising the protocol. This policy must be read in conjunction with the EWS tool (as per the main policy) the EWS protocol flowchart and the Observations Policy.

General Points

• Each area utilising the EWS should have a named link nurse / worker who is responsible for ongoing education regarding the EWS and associated audit.

• A copy of the EWS policy should be available in all areas utilising the scoring tool.

• Within the Emergency Department the EWS will be recorded within the Resuscitation areas, Majors and Minor areas. The only exception will be the minor injury and primary care presentations where this will be done at the discretion of the nurse assessing the patient.

• The Clinical Decision Unit (CLDU) will utilise the Trust EWS policy.

• The protocol is split into three categories low, medium and high risk of deterioration, each defined by the EWS calculated following the observations.

The Measurement of Patient Parameters

• Patient parameters / observations should be measured by an appropriately trained and competent member of staff.

• The minimum standard is that observations are performed according to the agreed policy on patients in the Resuscitation, Majors & Minors areas of the department. Observations may occasionally need to be performed more frequently than is stated in the policy and this should be determined by the registered nurse / doctor caring for the patient. Frequency of observations in the minor injury unit should be determined by the registered nurse / doctor caring for the patient.

• All chart entries should be clear, legible, written in black pen and the time and date of the observations clearly documented or inputted into the patientrack system.

• A full set of observations should always be recorded, to include respiratory rate, heart rate, systolic blood pressure, temperature, neurological status and oxygen saturations.

• Observations should be documented on the Patientrack system or the observation chart by the person performing the measurements.

• Frequency of observations will be determined by the policy flowchart ( page 5 and 6). Minimum observation frequency will be at admission, one hour following admission and four hourly and / or pre-discharge as per Trust policy

Calculation of the Early Warning Score

• The EWS will be calculated for every set of observations

• The total EWS and individual parameters scores will be documented for every set of observations.

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Appropriate intervention utilising the Protocol

• At any time, in the light of actual or anticipated severe deterioration or there is cause for concern, consider immediate direction to high risk category and be referred to the middle grade or Consultant immediately. Referral to Critical Care should be considered by middle grade of above.

• Observations and EWS must be performed at triage on all patients excepting isolated limb injuries and primary care presentations.

• Observations will be repeated within one hour of arrival in the Emergency Department.

• A EWS ≥ 3 triggers the start of the EWS flowchart

• In patients triggering EWS ≥ 3, observations should be repeated hourly as a minimum. Low Risk category

• Following an EWS = 3, the primary nurse for the area will be informed who must attend the patient within 1 hour, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour. The nurse co-ordinator will also be informed.

• For a second EWS = 3, the primary nurse and the middle grade doctor will be informed who must attend within 1 hour, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour. The nurse co-ordinator will also be informed.

• For a third and fourth EWS = 3 the primary nurse for the area and the middle grade doctor will be informed who must attend within 1 hour and consider an arterial blood gas. The nurse co-ordinator will also be informed.

• For a fifth EWS = 3 go to the medium risk category and continue until score is reduced.

Medium Risk category

• Following an EWS = 4 or 5 or EWS =3 on five consecutive occasions for the same patient. times, the nurse coordinator and the middle grade doctor will be informed who must attend within 20 minutes, assess the patient and institute an appropriate intervention. Observations should be rechecked within 1 hour

• For a second EWS = 4 or 5 or EWS =3 on six consecutive occasions for the same patient, the middle grade doctor must re-attend within 20 minutes and an arterial blood gas should be taken and further assessment and treatment implemented. Observations should be rechecked within 1 hour

• For a third EWS = 4 or 5 or EWS =3 on seven consecutive occasions for the same patient, then the doctor must re-attend within 20 minutes and further assessment and treatment implemented. Observations should be rechecked within 1 hour

• For a fourth EWS = 4 or 5 or EWS =3 on five consecutive occasions for the same patient, go to high risk category

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High Risk category

• Any patient triggering an EWS ≥ 6, on five consecutive occasions for the same patient EWS = 4 or 5 or EWS =3 nine times, the nurse coordinator will be informed and the patient must be seen by an Emergency Department middle grade or consultant within 10 minutes and an arterial blood gas should be taken and further assessment and treatment implemented. They should have observations repeated a minimum of hourly

• If a second EWS ≥ 6, sixth EWS =4 or 5 or EWS = 3 on ten consecutive occasions for the same patient, they must be reviewed by the Emergency Department middle grade or consultant and consider referral to Critical Care. On each subsequent EWS ≥ 6 they must be reviewed by the Emergency Department middle grade or consultant within 10 minutes until score improved or parameters altered or an appropriate referral has been made

• If a patient has a chronic alteration to one or more of the measured parameters e.g. elevated heart rate due to chronic atrial fibrillation it may be appropriate to alter the scoring criteria for that parameter. On the extremely rare occasions that this should be necessary this alteration can only be done by a middle grade or consultant following a full assessment (consider ABGs)

• The ED team (middle grade and consultant) should consider contacting the Critical Care medical team if they are unable to reduce the EWS to ≤ 6 despite full resuscitation.

• If a patient has been accepted by a medical specialty, they will be contacted regarding EWS triggers and the Trust EWS policy should be adhered to

• All EWS trigger responses must be documented in the patient’s medical and nursing notes.

• A patient must always have a full set of observations one hour after a EWS trigger with recalculation of the EWS (appendix 3).

• If EWS scoring parameters are altered it must be documented in the patient’s medical notes and the new scoring criteria recorded on the observation chart or altered on the Patientrack system.

• The triggering threshold e.g. EWS ≥3 should never be altered.

• All patients being transferred to the wards MUST have a full observation set performed within the fifteen minutes prior to the transfer.

• If a patient requires transfer to another clinical area (including the ward) and has a EWS ≥3 or concern is expressed about the clinical course of the patient then under these circumstances an ED middle grade / consultant must assess the patient prior to transfer. See Trust transfer policy (latest version on intranet). This assessment should determine if the patient is medically stable enough for transfer or if intervention is required to stabilise the patient prior to transfer. This policy applies equally to patients admitted from the Emergency Department to the CLDU.

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