CCDHB Early Warning Score (EWS)
Welcome to the EWS and vital sign chart e-learning site.
This resource provides an opportunity to learn about the use of the new adult EWS system which is being introduced across
Capital & Coast and Hutt Valley DHBs.
The online training will help you learn how to fill in the new charts and operate the escalation pathway.
Please note that the adult EWS is designed for use in adults aged
16 years and above. For children please refer to the PEWS system or for pregnant patients please use MEOWS.
Begin Training
Resources
Pdf 1. EWS matrix
Pdf 2. EWS chart
Pdf 3. Escalation pathway

o Learning objectives o EWS parameters o Calculating an EWS & recording vital signs o Triggering an EWS response & escalation o EWS Quiz

After completion of this e-learning session you will be able to:
1. Understand the benefits of CCDHB’s EWS
2. Describe the seven EWS parameters
3. Calculate an EWS correctly
4. Describe CCDHB’s EWS triggers for initiating a response
5. Outline how the EWS escalation pathway works
6. Understand how the EWS Modification Box is used

Early Warning Scores (EWS) have been developed internationally to help identify acutely ill and deteriorating patients in acute care hospitals
EWS systems focus on the EARLY recognition of the clinical signs of deterioration. Having recognised at-risk patients, the system then trigger an escalation response to prevent further deterioration that may lead to a cardiac arrest. This EARLY approach to acute deterioration optimises patient outcomes.

The NEWS (National Early Warning Score from the UK
NHS) is the only evidence-based EWS system. It is better at predicting death, cardiac arrest or ICU admission than any other published EWS system.
(Prytherch, Smith, Schmidt & Fetherstone, 2010)
The new CCDHB EWS system is based on NEWS and modified to include emergency escalation for patients at high risk of imminent death.

There are 7 parameters that form the basis for
CCDHB’s EWS:
– Respiratory rate
– Oxygen saturation
– Supplemental oxygen administration
– Temperature
– Systolic blood pressure
– Heart rate
– Level of consciousness

• An elevated respiratory rate is one of the most sensitive indicators of acute illness in adult patients
• A reduced respiratory rate may be an indicator of narcosis or neurological depression
• To measure respiratory rate accurately, the patient’s breathing must be assessed for a full minute

• Measurement of oxygen saturation by pulse oximetry is now standard practice in acute care settings
• Decreased oxygen saturations can be an indicator of impaired pulmonary or cardiac function
• When using a pulse oximeter, make sure that the nail/skin interface is clean from anything that might impair the trace such as nail polish

• Patients who acutely require any
supplemental oxygen (via face mask or nasal cannula) to maintain oxygen saturation are, by
the fact they need oxygen, recognised to be at a higher risk of deterioration
• As such a score of 2 is added to the EWS when supplemental oxygen is used on any patient
• Oxygen is a drug and must be prescribed along with the intended target oxygen saturations

• Extremes of body temperature are sensitive markers of acute illness
• A low temperature (hypothermia) may be an indicator of severe infection or endocrine derangement
• A high temperature (hyperthermia) can be an indicator of acute infection, inflammation, brain injury or a reaction to certain types of drugs

• A low blood pressure (hypotension) is a significant marker of acute deterioration and may be due to sepsis, dehydration, cardiac failure or rhythm disturbances as well as the effects of medication
• A high blood pressure (hypertension) is an important risk factor for cardiovascular disease and may be related to another acute process (such as a stroke or severe pain)
• To capture the most accurate blood pressure, it is necessary to use a manual blood pressure cuff. When measuring blood pressure with a rapid irregular heart beat, automatic devices are less accurate

• Heart rate is an important indicator of any acute condition
• A fast heart rate (tachycardia) may be due to a number of causes:
– An arrhythmia
– Sepsis
– Metabolic disturbances
– Pain, nausea or distress
– Medications or reactions to them
• A slow heart rate (bradycardia) may be due to a heart block, altered conscious state, or electrolyte disturbances. It may also be a consequence of medication (beta blockers) or physical fitness
• When assessing the heart rate it is best practice to manually feel
(palpate) the pulse, rather than rely on pulse oximetry. Palpation will provide additional important clinical information such as skin temperature, regularity and strength of the pulse

A decreased level of consciousness may be a late sign of deterioration. It can be caused by a large number of conditions including sepsis, low blood pressure, stroke or drug effects
The AVPU assessment is a quick tool to measure a patient’s level of consciousness. The best response should be recorded:
A – a lert or awake
V – responds to v oice
P – responds to a p ainful stimulus
U – u nresponsive to all stimuli

• When a patient is admitted acutely, a full set of vital signs
with EWS calculation must be carried out every SIX hours for
the first 24 hours of admission (Essential Vital Sign
Measurement & EWS protocol 1.3091)
• The frequency for taking vital signs should be increased or decreased according to the clinical need of the patient
• Each vital sign is scored so that the more abnormal it is, the higher the EWS. The scores range from 0 (normal) to 3 (very abnormal)
• The individual scores for each parameter are added together to calculate a total EWS that, if abnormal, triggers a clinical response

The vital sign charts are colour-coded to identify each EWS zone: o White = normal o Yellow = potential to deteriorate o Orange = indicates acute illness or unstable chronic disease o Red = likely to deteriorate rapidly o Blue = immediately life threatening critical illness
CCDHB’s EWS system also allows for single parameter scoring i.e. if any vital sign falls in a coloured zone, the associated action is triggered

1. Measure & document a
full set of vital signs
2. Calculate & document the
EWS
3 . Use the
EWS to identify the appropriate level of escalation
4. Consider most appropriate clinical setting for ongoing care

18

In addition to the general adult vital signs chart, there are different charts for certain specialties:
– Neurology/Neurosurgery
– Cardiology
– Cardiothoracic
– High Dependency Area
Paediatric & Maternity services have different
EWS systems (PEWS & MEOWS) adjusted for the different vital sign values with age & pregnancy

The escalation pathway is MANDATORY across all clinical areas where EWS is in use
There are four levels to the CCDHB escalation pathway

EWS 1-5

• The EWS system does not replace sound clinical judgment
• If the ‘Mandatory Action’ does not occur within the time specified, escalate to the next coloured zone
• If you are seriously concerned about any patient, regardless of their vital signs or their
EWS, dial 777 immediately & ask for a Medical
Emergency Team (or ‘MET’). Give your location
& stay with the patient until help arrives.

• There are cases when clinically stable patients may have abnormal vital signs that are ‘normal’ for them. To accommodate this and prevent alarm-fatigue from overtriggering patient reviews, the EWS can be modified
• Any modification to the EWS must be made by a Consultant or
Registrar and should be regularly reviewed by the primary medical team to ensure it is still valid

• Modification to EWS must NEVER be used to normalise abnormal vital signs in clinically unstable patients, or to deter ward staff from accessing the help they need i.e. to prevent 777 calls from being made appropriately on deteriorating patients
• Any modification that is not signed & dated must be ignored
• Any patient in whom Cardiopulmonary Resuscitation (CPR) or a
Medical Emergency Team (MET) call is inappropriate can have this notified on their Vital Signs Chart. All limitations must also be documented in the patient’s clinical record

• EWS focus on early recognition of clinical signs and help identify deteriorating patients
• EWS have been shown to decrease numbers of in-hospital cardiac arrest


• CCDHB’s EWS is based on a validated system which has been demonstrated to be superior to other EWS systems at predicting in-patient cardiac arrest or death 
Submit Answer

• What are the 7 EWS parameters?
– Temperature
– Heart rate


– Level of consciousness 
– Urine output 
– Oxygen saturation 
– Systolic blood pressure 
– Supplemental oxygen 
– Diastolic blood pressure 
– Respiratory rate 
Submit Answer

Which of the vital signs is considered the most sensitive indicator of acute illness?
– Temperature
– Heart rate


– Respiratory rate 
Submit Answer

At CCDHB, what is the minimum frequency of vital signs to be taken on every patient within 24 hours of admission?
 – Daily
– Once per shift
– 6 hourly


Submit Answer

Use the CCDHB EWS Matrix (insert link to EWS matrix) to calculate the EWS:
– Respiratory Rate
– Oxygen Saturation
32
95%
– Supplemental Oxygen 4L/min
– Temperature
– Systolic BP
36.6
155
– Heart Rate
– Conscious level





132 
Alert, but tired 
Submit Answer

– Respiratory Rate
– Oxygen Saturation
32
95%
– Supplemental Oxygen 4L
– Temperature
– Systolic BP
36.6
155
– Heart Rate
– Conscious level
132






Alert, but tired 
Escalation
Response
The correct
EWS is 9

Use the CCDHB EWS Matrix (insert link to EWS
Matrix here) to calculate the EWS:
 – Respiratory Rate
– Oxygen Saturation
20
97%
– Supplemental Oxygen 8L
– Temperature
– Systolic BP
37.8
105
– Heart Rate
– Conscious level
98
Alert






Submit Answer

– Respiratory Rate
– Oxygen Saturation
20
97%
– Supplemental Oxygen 8L
– Temperature
– Systolic BP
37.8
105
– Heart Rate
– Conscious level
98
Alert
Escalation
Response
The correct
EWS is 4








Use the CCDHB EWS Matrix (insert link to EWS
Matrix here) to calculate the EWS:
 – Respiratory Rate
– Oxygen Saturation
9
92%
– Supplemental Oxygen Room Air
– Temperature
– Systolic BP
37.2
115
– Heart Rate
– Conscious level
48
Voice






Submit Answer

– Respiratory Rate
– Oxygen Saturation
9
92%
– Supplemental Oxygen Room Air
– Temperature
– Systolic BP
37.2
115
– Heart Rate
– Conscious level
48
Voice
Escalation
Response
The correct
EWS is 8








Consider most appropriate clinical setting for ongoing care
Use the EWS to identify the appropriate level of escalation
Calculate & document the
EWS
Measure & document a
full set of vital signs

The general adult EWS chart is used throughout adult wards at Kenepuru and Wellington campuses
The adult EWS is designed for adults over the age of 16 years
The colour-codes used to help identify each EWS zone are: yellow, orange, red and blue




The EWS replaces sound clinical judgment
The EWS can only be modified by a
Consultant or Registrar
Red is the colour associated with triggering
MET


