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
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.
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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
B
A
R
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 …………………………………………
……………………………………………………………………………
Background
o
Reason for admission………………………………………………….
Recent Surgery
if yes ………………………………..….
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……………….
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 coordinator 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
10
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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