James Griffiths
Consultant EM
Barnsley
CEM FOAMed Network
@YorksHumberFoam
Objectives
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Evolution of Early Warning Scores
Rapid Emergency Medicine Score (REMS)
National Early Warning Score (NEWS)
EWS in the ED
Future work?
Conclusion
Background
First EWS
 Developed in 1997 by
Morgan et al
 Based on five
physiological
parameters:
 SBP
 Pulse
 Resp rate
 Temp
 AVPU
Morgan et al. Clin Intensive Care 1997;8:100
M(odified)EWS
 Surgical patients
 Deviation from normal
BP
 Urine output
 Potential benefit from
critical care
Stenhouse et al. Br J Anaesth 2000;84:663
Patients at risk
Score
SBP
3
2
0
1
2
3
71-80
81-100
101-199
HR
<40
41-50
51-100
101-110
111-129
≥130
RR
<9
9-14
15-20
21-29
≥30
Temp
<35
35-38.4
AVPU
<70
1
Alert
Subbe et al. Q J Med 2001;94:521-526
≥200
≥38.5
Voice
Pain
Unrespo
nsive
REMS
0
1
2
3
4
Age
<45
45-54
55-64
HR
70-109
55-69
110-139
40-54
140-179
<40
>179
RR
12-24
6-9
35-49
>49
SBP
90-129
70-89
130-149
150-179
<69
>179
GCS
>13
11-13
8-10
5-7
<5
O2
>89
86-89
75-85
<75
10-11
25-34
Olsson & Lind. Acad Emerg Med 2003;10:1040-1048
5
6
65-74
>74
NICE
 The National Institute for Health and Clinical
Excellence (NICE) have recommended that
physiological track and trigger systems should be used
to monitor all adult patients in acute hospital settings
NICE Clinical Guideline 50 (2007)
DoH Clinical Indicators
 The new Department of Health Quality Indicators that
will replace the four-hour standard record a time to
full initial assessment of patients attending EDs which
includes a pain score and early warning score in
patients arriving by 999 ambulance
Department of Health 2011
NEWS
 Royal College of
Physicians working party
July 2012
 Based on a large number
of vital signs from an
electronic patient
database
Prytherch et al. Resuscitation 2010. 81:932-937
Smith et al. Resuscitation 2013. 84:465-470
The Future?
Finally...
Smith et al. Resuscitation 2013. 84:465-470