Many critically ill patients will present to the emergency department. The initial clinical assessment of all patients is performed using the
Manchester Triage System. Patients will be managed based on their clinical need according to the initial triage assessment. A small but significant number of patients, who were relatively well on their initial assessment, will deteriorate during their stay within the emergency department becoming critically ill and will require further resuscitation. It is important that these patients are identified early and managed appropriately. The early warning score is a physiological scoring system that can help to identify their physiological deterioration. 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 medical 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, heart rate, systolic blood pressure, temperature, neurological status and oxygen saturations) 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 been recommended by the Critical Care Outreach report published in 2003 6 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 NHS Foundation Trust the EWS has been introduced in acute areas since 2001 and is linked to a protocol to ensure patients are assessed and treated by suitably experienced personnel in a timely fashion.
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
(appendix 2) and the Observations Policy (appendix 3).
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2.1 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.
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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.

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 (appendix 1). Within majors and resus the minimum observation frequency will be at admission, one hour following admission and four hourly and / or pre-transfer as per Trust policy. Within minors the minimum observations will be at admission, for those triggering on the EWS or there is cause for concern, one hour following and four hourly, otherwise for all other patients within minors, four hourly observations unless triggering when hourly observations commence.
3.1 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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3.2 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 (appendix 1).

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
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
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 eight consecutive occasions for the same patient, go to high risk category
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. 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.
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A patient must always have a full set of observations one hour after a EWS trigger with recalculation of the EWS (appendix 3).
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 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.
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All patients being transferred to the wards MUST have a full observation set performed within the fifteen minutes prior to the transfer.
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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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1. Franklin C & Mathews JK (1994) Developing strategies to prevent in hospital cardiac arrests: analysing responses for physicians and nurses in the hours before the event. Critical Care Medicine; 22; pg. 244-247
2. Sax F & Charlson M (1987) Medical patients at high risk for catastrophic deterioration; Critical Care Medicine; 15; pg. 510-515
3. Smith AF, Wood J (1998) Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey; Resuscitation; 37; pg. 133 - 137
4. Schein RMH, Hazaday N (1990) Clinical Antecedents to in-hospital cardiopulmonary arrest; Chest; 98 Pg. 1388 - 1392
5. Morgan R J M, Williams F & Right M (1997) An Early Warning Scoring System For Detecting Developing Critical Illness; Clinical Intensive
Care; 8 (2); pg. 100
6. DoH & Modernisation Agency (2003)
Version 3
Amended by
– Critical Care Outreach 2003 – Progress in developing services.
Sarah Ingleby
John Butler
Steve Jones
Jane Grimshaw
Lead Nurse Acute Care Team
Consultant in Emergency Medicine & Critical Care
Consultant in Emergency Medicine & Critical Care
Lead Nurse Emergency Services
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E WS should be calculated with each set of observations
Frequency of observations as per ED EWS policy
Appendix 2
High Risk of deterioration
Medium Risk of deterioration
If a patient is expected to deteriorate or is causing concern consider escalation to high risk category
Low Risk of deterioration
E
WS ≥ 6, Nurse coordinator informed and
ED middle grade or
Consultant review within
10 minutes assess, include arterial blood gas taken and institute
Obs repeated < 1 hr
Second EWS ≥ 6, Nurse coordinator informed and
ED middle grade or
Consultant review within
10 minutes. Consider referral to Critical Care
Team.
Obs repeated < 1 hr
All subsequent EWS ≥ 6 should be reviewed by the
Emergency Department middle grade or
Consultant within 10 minutes until score improved or parameters altered
Obs repeated < 1 hr
EWS = 4 or 5, Nurse coordinator informed and the ED middle grade review within 20 minutes, assess and institute intervention.
Obs repeated < 1 hour
EWS = 1 or 2
EWS = 3, Nurse co-ordinator informed review within 1 hour, assess and institute intervention.
Obs repeated < 1 hour
EWS = 1 or 2
2
EWS = 3
Low risk
EWS = 4 or 5
Medium risk
EWS = 3
Second EWS = 3, the nurse
Low risk coordinator informed and the
Second and third EWS = 4 or 5, Nurse coordinator informed and the ED middle grade review, within 20 minutes, assess, include arterial blood gas taken and institute intervention.
EWS ≥6
High risk middle grade doctor review within 1 hour, assess the
EWS = 4 or 5
Medium risk patient and institute.
EWS ≥6
Obs repeated < 1 hour
High risk
Obs repeated < 1 hour
Third & forth EWS = 3 the nurse coordinator informed and the middle grade doctor review within 1 hour, assess, consider an ABG and institute intervention
Obs repeated < 1 hour
Forth EWS = 4 or 5 or EWS
=3 eight times, go to high risk category
Fifth EWS = 3 go to the medium risk category and continue until score is reduced
Obs repeated < 1 hour
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