EWS – Procedure for Using the Early Warning Score and Early ...

EWS – Procedure for Using the
Early Warning Score and Early
Detection of the Deteriorating
Patient
Ref CLIN-0076-v1
Status: Ratified
Document type: Procedure

Contents
1. Introduction ....................................................................................................... 3
2. Why we need this procedure ........................................................................... 3
2.1. Purpose .............................................................................................................. 3
2.2. Objectives ........................................................................................................... 3
3. Scope ................................................................................................................. 3
3.1. Who this policy applies to ................................................................................... 3
3.2. Roles and responsibilities ................................................................................... 4
4. What is the Early Warning Score System? ..................................................... 4
4.1. Age considerations ............................................................................................. 5
5. Recording the Early Warning Score ................................................................ 5
6. Monitoring and frequency of observation ....................................................... 6
6.1. What if the patient has a DNAR? ........................................................................ 7
6.2. Palliative care/end of life ..................................................................................... 7
7. Increasing observations ................................................................................... 7
8. High baseline scores ........................................................................................ 7
9. Oxygen therapy ................................................................................................. 8
10. Documentation .................................................................................................. 8
11. Rapid tranquilisation ........................................................................................ 9
12. CAMHS and adult eating disorders ................................................................. 9
13. Lying and standing BP ..................................................................................... 9
14. Consent ........................................................................................................... 10
15. Related documents ......................................................................................... 10
16. How this procedure will be implemented ...................................................... 10
17. How this procedure will be audited ............................................................... 10
18. References ...................................................................................................... 11
19. Document control ........................................................................................... 11
Appendix 1 – Eating Disorders Early Warning Score .................................................. 12
Appendix 2 – Physical Obs Chart CAMHS .................................................................. 16
Appendix 3 – Early Warning Score Prompt Sheet ....................................................... 20
Appendix 4 – Trustwide Early Warning Score Chart .................................................... 22
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Early Warning Score and Early Detection of the Deteriorating Patient

1. Introduction
Many people who are admitted into our services are both physically and mentally unwell.
‘Any patient in hospital may become acutely unwell. However, the recognition of acute illness is
often delayed and its subsequent management may be inappropriate. This may result in late
referral and avoidable admissions to critical care, and may lead to unnecessary patient deaths,
particularly when the initial standard of care is suboptimal.’ (NICE 2007)
2. Why we need this procedure
2.1. Purpose
• Staff must be able to give evidence based, effective care which will ensure that the patients
receive appropriate, prompt and effective interventions.
• Despite being a Mental Health Trust, staff must be able to safely undertake the recording of
physiological observations and the use of the Early Warning Score ‘Trigger and Track’ system.
• The Early Warning Score should be associated with appropriate communication between
medical and nursing staff within the Trust and when dealing with acute and emergency
services.
• It is a recognised clinical tool which is constantly used by all medical teams including the
emergency services.
2.2. Objectives
• The main aim of this document is to set standards in practice to ensure that staff use the Early
Warning Score appropriately.
3. Scope
3.1. Who this policy applies to
• This clinical guideline applies to all clinical staff employed by Tees, Esk and Wear Valleys
NHS Foundation Trust (TEWV) or working on sites where the Trust provides services.
• This guideline has been produced to support all staff caring for patients in in- patient settings
and those treated with rapid tranquilisation.
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3.2. Roles and responsibilities
Role
Executive Director for Nursing
& Governance
Corporate responsibility
Individuals
Medical staff (including
physical care practitioners)
Ward managers/clinical leads
Trained nurses and healthcare
assistants
Glasgow coma scale (GCS)
Responsibility
• Overall responsibility for ensuring this guideline is implemented.
• Ensuring this guideline is supported by appropriate training,
policy distribution and awareness and incorporation into the
clinical governance agenda, in terms of audit.
• Adhering to professional codes of practice and ensure that
clinical knowledge and competence is maintained.
• Reviewing Early Warning Score charts on a regular basis.
• Responding to any staff concerns and to see the patient:-
• Within 2 hours if score of 2-3
• Immediately if score 4 and above
• On call medical staff if not on site must respond promptly
and consider advising staff to call emergency services if
appropriate
• Ensuring that staff have appropriate training and that the Early
Warning Score process is adhered to and that the Early
Warning Score is discussed regularly at report outs/ward
rounds.
• These are to ensure that the Early Warning Score is done as
per guideline and that high scores are effectively communicated
between each shift and between all disciplines.
• To seek training where needed.
• Health care assistants should report any high scores to a
trained member of staff but do have authority to call for medical
assistance or emergency services if they have sufficient
concern about any patient.
• The Early Warning Score and GCS are very closely linked
around physical observations especially in the management of
patients who fall or sustain a head injury. It is therefore
essential that staff are trained in the use of the GCS and that a
baseline GCS is recorded on the Early Warning Score chart.
4. What is the Early Warning Score System?
• The Early Warning Score scoring systems were introduced several years ago, are used in all
acute hospitals and have proven to be effective in the early detection of physical deterioration
of patients.
• These Early Warning Score systems have also been used effectively in community settings
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Early Warning Score and Early Detection of the Deteriorating Patient

and now need to be used in Mental Health units.
• The Early Warning Score is a combination of six physiological observations
o Respiration rate
o Systolic blood pressure (BP)
o Pulse
o Temperature
o Conscious level (AVPU = alert, voice,pain,unconscious)
o Oxygen saturations (Sats /SAO2)
• Each of the observations generates a score which in turn generates an overall score and this
can identify acute illness and shock.
• The Early Warning Score is set to trigger when a patient has abnormal physiology apart from
hypertension which is not a clinical emergency unless severe.
4.1. Age considerations
• Variances identified for different age groups (Doherty & Lister, 2008) are reflected within the
separate Early Warning Score Charts (Appendices 1 and 2).
• Give consideration to age, size and physical presentation with a baseline taken on admission
to ensure any changes are noted immediately
5. Recording the Early Warning Score
• Observations to be taken
o BP- using digital or manual equipment. (score is calculated on the systolic reading –
the top number)
o Pulse – rate is recorded using digital equipment or by counting manually. It is also
important to check rhythm of pulse also by manually feeling pulse at wrist
o Temperature- using digital equipment (tympanic thermomenter)
o Respiration rate- count respirations for 1 minute. Try not to let patient know you are
counting as this may affect rate.
o Saturation of oxygen – using pulse oximeter
o Conscious level
• New confusion/agitation
• A- alert and responsive
• V- needs to be spoken to to get a response
• P- need to apply painful stimuli for patient to respond
• U- unconscious and not responding to voice or painful stimuli.
• Record the Early Warning Score on the Trust chart, relevant for the area of work.
• Do not photocopy the chart- order originals from Cardea.
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• Colours are used on the chart to help identify severity of the decline in physical health.
o Yellow - 1
o Orange - 2
o Red - 3
• Use the back of the charge to determine the correct score if the observation being recorded falls
on the border between two colours.
• Record the Early Warning Score daily unless in exceptional circumstances such as palliative
care or severe aggression.
• The Early Warning Score is a tool which is used to assist clinical judgement and is not
prescriptive.
6. Monitoring and frequency of observation
• On admission, a baseline set of observations must be recorded on the front of the chart in
relevant section. This is applicable to all patients admitted to in-patient units, including respite
beds.
• Refusals must be recorded and staff are to try again at regular intervals until obtained.
• Unless stated otherwise the observations and Early Warning Score are to be recorded daily.
• This is applicable to all in-patient settings.
• This can be anytime during the daytime period.
• If the Early Warning Score is not to be recorded daily, then this is to be clearly recorded in the
special notes and reason given. A decision not to record the Early Warning Score on a daily
basis must be a multidisciplinary decision.
o If this is the case an intervention plan is required and the decision needs to be reviewed
at least every month. If there is any deterioration or change in presentation then the
Early Warning Score should be taken and the intervention plan reviewed with a view to
the interval of recordings to be adjusted accordingly.
• The Early Warning Score must be recorded day or night if the patient shows any signs of
physical illness even if it has been recorded earlier in the day.
• The Early Warning Score must be repeated at the intervals stated when a score above baseline
is obtained.
• The Early Warning Score must be recorded in the event of a fall along with the Glasgow Coma
scale.
o This must be at immediately following fall, then as indicated by score or if patient shows
signs of deterioration.
• The Early Warning Score must be recorded every 10minutes following rapid tranquilisation
o Parenteral – every 10 mins for one hour, then half hourly until the patient is ambulatory
o Oral – every half hour until patient is ambulatory.
o If neuroleptic naïve then follow parameters for parenteral.
o If Early Warning Score cannot be done due to aggression then monitor breathing as a
minimum.
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6.1. What if the patient has a DNAR?
• The Early Warning Score must still be recorded if a ‘Do not attempt resuscitation’ (DNAR) is in
place unless the patient is deemed to be end of life or palliative care. Many people have a
DNAR but this is for non-resuscitation in a cardiac arrest and does not mean that the Early
Warning Score should not be recorded.
6.2. Palliative care/end of life
• Palliative / end of life care is when the multidisciplinary team, including medical staff, have
deemed that the patient is not likely to respond to any treatment and have decided that no
active medical intervention is to be carried out in the best interests of the patient. This should be
in agreement with the patient if possible and the carers/ family members.
• This decision must always be recorded on the Early Warning Score chart.
7. Increasing observations
• A high Early Warning Score may trigger an increase in the frequency of the Early Warning
Score recording. Parameters for this are on the back of the chart.
• Some patients may have a regularly high Early Warning Score due to chronic illness either
mental or physical. (e.g. anxiety or Chronic Obstructive Pulmonary Disease (COPD) may cause
high respiration rate).
• The standard trigger setting of 4 will prompt a medical review. This is to ensure that a patient
with altered physiology is appropriately and promptly reviewed.
• The medical review may result in a revised monitoring and management plan or a different
trigger setting. This must be recorded on the special notes on the front of the chart.
• Triggers and management plan changes can only be decided by medical staff or physical care
practitioners.
• An intervention plan is also required.
• If there is a single score of 3 in any observation category, then this must trigger urgent medical
attention.
8. High baseline scores
• High baseline scores could be due to chronic illness but could equally be due to acute illness or
anxiety related to the admission.
• If the baseline and subsequent Early Warning Score is always raised at 1 or 2, then this must
be taken into account when responding to the score. i.e. if the patient normally scores 2 for high
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Early Warning Score and Early Detection of the Deteriorating Patient

espiratory rate but today scores 0 for respiratory rate and 2 for BP then action is required.
• There must be a record of this persistently high Early Warning Score and why action was not
required.
9. Oxygen therapy
• Oxygen therapy must be considered if saturation levels of 92% or less or if they have an Early
Warning Score of 4 or more.
• This should be via a non re-breath mask (with reservoir) at 15 litres per minute.
• Oxygen does not have to be prescribed in this situation.
• Medical advice must be sought.
• There is concern that people with chronic obstructive airways disease are at risk of
hypercapnea if they receive prolonged administration of oxygen.
o The British Thoracic Society (2008) advises that oxygen can be administered in an
emergency situation target saturation of oxygen is lower at 88-92% and that the flow of
oxygen administered should be adjusted to maintain that.
• In the event of collapse, cardiac or respiratory arrest then high flow oxygen is to be given. In the
event of a high early warnings core without collapse, the persons baseline must always be
considered and if oxygen is required then immediate medical assessment is required.
• All should be documented in clinical record.
10. Documentation
• The paper copy of the Early Warning Score must always be used
• The Early Warning Score charts should be kept in a file with guidance and standard description
process.
• All entries must be dated and the time to be recorded in the 24 hour format.
• If the Early Warning Score is being taken more frequently than daily or in the case of rapid
tranquilisation, then the reason must be recorded on the chart and electronic record.
• Daily normal readings need not be recorded on Paris however must be included in MDT
meetings or daily report outs.
• All high scores and action taken must be recorded on Paris as they occur.
• Any further advice and events related to the high Early Warning Score must be recorded.
• Following rapid tranquilisation, all readings must be recorded on Paris. When the recordings are
reduced back to previous interval of recording, the reason for the discontinuation must be
recorded.
• It is vital that if Early Warning Score cannot be recorded following rapid tranquilisation, then the
reason must be clearly recorded.
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• When a new chart is required, a new set of baseline observations must be inserted on the front
page.
• Recording the observations
o BP. Record as crosses with vertical broken lines
o Pulse. As dot with lines joining previous days entry
o Respiration. As dot with line joining previous days entry
o Temperature. As dot with line joining previous days entry
o AVPU. Tick in correct box
o Saturation of oxygen. Actual level to be written in box.
.
11. Rapid tranquilisation
There is Trust policy on the use of the Early Warning Score with rapid tranquilisation.
This policy must be adhered to and requires more intense monitoring of the physiological
observations.
• Oral administration- monitor Early Warning Score every half hour until patient is ambulatory.
• Parenteral- monitor Early Warning Score every 5-10 mins for 1 hour then every half hour until
the patient is ambulatory.
• If the patient is neuroleptic naïve – follow parameters for parenteral.
• If the patient refuses to have the observations taken or is too aggressive, then a minimum of
respiration rate is required but timings must be in accordance with policy and refusal must be
documented on chart and on Paris.
12. CAMHS and adult eating disorders
• Children parameters vary from adult parameters so it is appropriate that the standard
Early Warning Score chart is not used and a variation will be used.
• Adult eating disorder patients require more intense monitoring and an alternative
response to high scores so an alternative chart will be used.
• Do not use any other charts.
13. Lying and standing BP
• When recording lying and standing BP, the Early Warning Score should be calculated using the
lying BP only. Using the standing BP if there is postural drop may result in an elevated score
which does not indicate shock or deterioration.
• The standing BP should be recorded on the chart with the remaining observations left blank.
o Alternatively both lying and standing BP can be recorded in same box.
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• It is important to identify which BP is lying and which is standing by using full words or L&S.
• Lying and standing BP must be reviewed by medical staff at least weekly.
14. Consent
• Valid consent is required from the service user. If a service user lacks capacity to consent,
please refer to the Mental Capacity Act/ Mental health Act.
• In a life saving situation where consent cannot be obtained or capacity to consent assessed,
then staff must act in the patients best interests and administer basic life support measures and
seek immediate medical attention.
15. Related documents
Rapid tranquilisation policy
Resuscitation Policy
16. How this procedure will be implemented
• This procedure will be published on the Trust’s intranet and external website.
• Line managers will disseminate this procedure to all Trust employees through a line
management briefing.
• All staff are to attend training sessions about the use of the Early Warning Score.
• All staff need to be competent in the taking of physiological observations and Trust training must
be accessed if required.
17. How this procedure will be audited
• Ward/Unit Managers will ensure individual staff training records are maintained and
competence is reviewed annually at appraisal.
• Service specific and Trust wide audits will be carried out to assess compliance with this
guideline.
• Service specific audits must be yearly and comprise of assessment of compliance with the
procedure and also staff competency in taking, recording and interpreting readings.
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18. References
Nice (2007) Acutely ill patients in hospital. Recognition of and response to acute illness in adults in
hospital.
19. Document control
Date of approval: 2 May 2013
Next review date: 2 May 2016
This document replaces:
N/A
Lead: Name Title
Lesley Chapman
Associate Nurse Consultant
Members of working party: Name Title
This document has been
agreed and accepted by:
(Director)
This document was approved
by:
Lesley Chapman
Corrie Burton
Anne Thomas
Bernadette Johnson
Name
Chris Stanbury
Name of committee/group
Associate Nurse Consultant
Physical Care Practitioner
Physical Care Practitioner
Physical Care Practitioner
Title
Director of Nursing and Compliance
Date
This document was ratified by: Name of committee/group Date
QuAC 2 May 2013
An equality analysis was
completed on this document
on:
September 2012
Amendment details:
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Early Warning Score and Early Detection of the Deteriorating Patient

Appendix 1 – Eating Disorders Early Warning Score
Physiological observations, track
and trigger monitoring system
Eating Disorders Unit (Associated Trust guideline: CG100a)
Name:
Address:
DOB:
CRN/ Hospital No:
NHS Number:
Monitoring Plan:
• Medical HDU patients to have 4 hourly recording of ALL observations (RR, O2 sats, temp, BP,
HR and AVPU)
• All other patients to have recording of observations once per day
• For every set of observations performed an Early Warning Score (EWS) must be calculated
• A low BM and reduced level of consciousness (V,P or U) suggest sepsis – contact doctor
• A low oxygen level (92% or less) always requires medical team assessment (or on-call
doctor) – attach a non-rebreath mask with 10l/min of O2 and urgent review by doctor
• Call for help as per graded response (see back of chart)
IF ANY PATIENT AT ANY TIME IS CAUSING CLINICAL CONCERN CALL FOR HELP WITHOUT
DELAY.
Prescribed Frequency of Observations if changed from above (Nurse or Doctor)
Date: Time: Frequency: Changed by: Print name: Designation:
(Signature)
(BLOCK CAPITALS)
On occasion the EWS parameters may not be specific enough for a particular patient, if so please complete
the following and Respond as to Medium Level above if patient exceeds these parameters
Prescribed Patient Specific Parameters (Completed by a Doctor)
Parameter
Heart rate
Respiratory rate
Systolic BP
Saturations
Urine Output
Blood Glucose
EWS
Upper
limit
Lower
limit
Signature
Print name
(BLOCK CAPITALS)
Designation
Date and
Time
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Early Warning Score and Early Detection of the Deteriorating Patient

Physiological observations, track
and trigger monitoring system
Eating Disorder Unit
Respiratory
Rate
Enter actual rate
Oxygen
Saturation
Enter actual reading
Temperature
Enter dot ·
Blood
Pressure
EWS SCORE
Uses Systolic
Record as
& enter actual
pressures
Heart Rate
Enter dot
& actual rate
Level of
Consciousness
Tick appropriate box
Date:
Time:
31 + 3
23 – 30 2
19 – 22 1
9 – 18 0

Physiological observations, track
and trigger monitoring system
Eating Disorder Unit (Associated Trust guideline: CG100)
Name:
Address:
DOB:
CRN/ Hospital No:
NHS Number:
Respiratory
Rate
Enter actual rate
Oxygen
Saturation
Enter actual reading
Temperature
Enter dot ·
Blood
Pressure
EWS SCORE
Uses Systolic
Record as
& enter actual
pressures
Heart Rate
Enter dot ·
& actual rate
Level of
Consciousness
Tick appropriate box
Date:
Time:
31 + 3
23 - 30 2
19 - 22 1
9 - 18 0

Physiological observations, track
and trigger monitoring system
Eating Disorder Unit (Associated Trust guideline: CG100)
Name:
Address:
DOB:
CRN/ Hospital No:
NHS Number:
Graded Response to EWS (record actions taken in the table below)
• Total EWS 0-1 • Continue to monitor as above no further action required
• Total EWS 2-3
• Clinical ‘concern’
• Single Parameter scores 3
• Specific Parameter trigger
• Total EWS 4-5
• Clinical ‘concern’
• Total EWS 6 or more
• Rapid deterioration / clinical
emergency
• If clinical concern for other reasons contact medical team or on-all doctor
• Contact medical team or on-call doctor
• Medical team (or on-call doctor) to do ABCDE assessment & repeat EWS
• Contact medical team or on-call doctor
• Medical team (or on-call doctor) to do ABCDE assessment & repeat EWS
• Consider transfer to medical ward
• Fast bleep medical team or on-call doctor
• Call “999” if out of hours & on-call doctor nor immediately available
• Immediate transfer to medical care
• Cardiac arrest call (if appropriate)
Record at Risk Incidents – EWS 3 or more
Date
and
time
Comment
Action taken
Signature
Print name
(BLOCK CAPITALS)
Designation
Actioned by:
Signature
Print name
(BLOCK CAPITALS)
Designation
Date and time
Use Continuation Sheet HCR127 for further variance recording.
For all patients EWS 3+ - Assess Patient as per ABCDE Approach, Maintain Airway if compromised and add
supplementary oxygen. Consider increasing the frequency of observations If EWS remains raised follow graded
response and ensure that a doctor Reviews Treatment Plan, (refer to associated guideline CG100)
Nausea Score:
0 – None
1 – Nausea
2 – Nausea requiring treatment
3 - Vomiting
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Appendix 2 – Physical Obs Chart CAMHS
Physiological Observation & Early Warning Score Chart for the care of the deteriorating
patient including post rapid tranquilisation (children 12-18 years of age)
Patient’s name
NHS Number
Ward
Consultant
Weight Height BMI
Admission/baseline observations
BP
Pulse
Resp rates
Sats
Date taken
Temp
This tool is to assist, not replace, clinical judgement. Baseline observations should always be
taken into account when assessing for signs of deterioration.
The Policy for the Implementation of Rapid Tranquilisation (CLIN/0014/v5(2), page 8) states: ‘Following
administration of medication, patients should be monitored as per service specific protocols. Information on remedial
measures, which may be needed following administration of rapid tranquilisation, are also identified. It is
particularly important to undertake frequent and intensive monitoring of a sedated/non ambulatory patient.
Pay particular attention to regular checks of airway, level of consciousness, pulse, blood pressure, respiratory effort,
temperature and hydration.’
Following administration of parenteral rapid tranquillisation frequency of physiological observations –
every 5-10 minutes for one hour then every half hour until the patient is ambulatory. If the patient’s levels
of agitation and risk increase due to the regularity of the observations, the nurse may use their clinical
judgement as to the frequency of observations following discussion with the doctor. They should continue
to observe for signs and symptoms of deterioration (as below).
Following administration of oral rapid tranquillisation frequency of physiological observations – every
half hour until the patient is ambulatory unless patient is neuroleptic naïve in which case follow parameters
for parenteral. If the patient’s levels of agitation and risk increase due to the regularity of the observations,
the nurse may use their clinical judgement as to the frequency of observations following discussion with
the doctor. They should continue to observe for signs and symptoms of deterioration (as below).
If the patient refuses to have physiological observation taken staff should document this in the
patient’s electronic records and observe for signs and symptoms of deterioration (as below) and document
these on the EWSC form.
Observing for the deteriorating patient. Generally there are signs that a patient is becoming unwell.
These early signs can often be recognised by a visual assessment of the patient. Usually the first indicator
that something is wrong is a change in respiratory rate. These visual signs may include: rapid/noisy
breathing (wheeze, rattle), minimal respiratory effort or respiratory distress (gasping). Other signs of a
deteriorating patient include: pallor, clammy, cyanosis (blue lips, extremities), shivering or a new onset of
confusion/agitation.
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EARLY WARNING SCORE CHART
EWS 3 2 1 0 1 2 3
Systolic
BP
60 or less 61-65 66-99 100-120 121-140 141-149 150 or
over
Resp 10 or less 11-12 13-14 15-20 21-24 25-29 30 or over
rate
Temp 35 or less 35.1-35.5 35.6-36 36.1-37.5 37.6-38.5 38.6-38.9 39 or over
Sats 93%
Pulse 35 or less 36-50 51-59 60-100 101-115 116-125 126 or
over
CNS Completely Responds Responds Alert Confusion
unresponsive to pain to voice
(Parameters agreed in liaison with the C&YPS team and consultation with paediatrics,
James Cook University
Hospital)
Accumulative EWS of 1-3
Inform nurse in charge of ward/unit. If patient is known to have
physical ailments (e.g. asthma) or presents in a manner that raises
concern inform doctor
Accumulative EWS of 4 -5
Inform nurse in charge of ward/unit. Contact doctor immediately and
seek advice. Request doctor to attend, if unable to do so
immediately and status worsens call the emergency services
Accumulative EWS 6 and above
Inform nurse in charge of ward/unit. Contact doctor immediately
inform them of status of the patient, call the emergency services.
Red zone EWS one single category
Inform nurse in charge of ward/unit and doctor immediately. If
patient is known to have physical ailments (asthma) or presents in a
manner that raises concern seek advice from doctor and consider
contacting the emergency services
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Date
Observation Chart
Time
Systolic Blood Pressure mmHg
Resp Rate
Temperature
150+ 3
145
140
2
135
130
1
125
120
115
110
0
105
100
95
90
85
80
1
75
70
65 2
60 and below 3
30+ 3
25-29 2
21-24 1
15-20 0
13-14 1
11-12 2
10 and below 3
39 + 3
38.6-38.9 2
37.6-38.5 1
36.1-37.5 0
35.6-36 1
35.1-35.5 2
35 and below 3
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Date
Observation Chart
Time
Sats
Pulse
Alertness
93+ 0
90-92 1
85-89 2
85 and below 3
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
Confusion
Alert/ambulatory
1
0
Responds to voice 1
Responds to pain 2
3
Completely
unresponsive
BP score
Resps score
Temp rate
Sats score
Pulse score
Alertness levels
EWS total
Initials
Initials
3
2
1
0
1
2
3
BP
Resps
Temp
Sats
Pulse
Alertness
EWS
Initials
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Appendix 3 – Early Warning Score Prompt Sheet
Early Warning Score Prompt Sheet (EWS)
The early warning score chart is a tool to assist staff to identify when a patient is physically unwell.
We are looking for signs of shock which may be detected by clinical observations and changes in
these observations can occur several hours before the patient becomes visibly unwell.
• The EWS chart
o Is available on Cardea and only originals should be used.
o The chart is not to be photocopied as a continuation sheet as the information on the
front and back cover is essential to its use
• Frequency of the EWS recordings
o In MHSOP the EWS is to be completed daily.
o It is to be recorded daily throughout the patients stay.
o No set time of day
o The EWS is always to be used following a fall, after rapid tranquilisation or if patient
appears unwell.
• Exceptions to the daily EWS :-
o Palliative care patients who have a care plan in place for no further treatment
o Aggressive/ resistive patients. EWS must be attempted if rapid tranquilisation is used.
o This needs to be re-evaluated on a weekly basis and must be discussed at MDT.
o An intervention plan should be written to explain why daily EWS not recorded and
when EWS should be taken.
• Using the chart
o The top (systolic) BP is the one which is used in the score.
o Don’t use numbers in the squares. Use dots and join this to previous days to create a
graph. (except BP)
BP x
X
Pulse, temperature, pulse
Saturation of oxygen as the actual number e.g. 92
AVPU a tick in the appropriate box
o
o
o
o
Remember to refer to the baseline if a high EWS is found.
EWS is a tool and does not replace clinical judgement.
Guidance for frequency of recording and actions required are on the back page of the
EWS chart.
If the observation is on a line between 2 colours (on the line) look at the back of the
chart what the score should be.
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o
o
o
o
Make sure base line observations are completed.
If a patient refuses then this must be recorded on the chart
When a new chart is commenced, use an up to date set of base line observations.
Inform emergency services of EWS if they are called.
• High baseline EWS scores
o If the baseline EWS is always 1-2 then this should be taken into account when
responding to the score
o For example if patients EWS is always 2 then no action is required until they score
above this. (Will not require 4hrly obs on score 2). This must however be documented
on PARIS and the actual chart. Write EWS normally 2
o In the event of a high EWS and this is not the patient’s normal then appropriate action
should be taken and the EWS repeated as directed on the back of the chart.
• Rapid tranquilisation
o Oral administration- monitor EWS every half hour until patient is ambulatory.
o Parenteral- monitor EWS every 5-10 mins for 1 hour then every half hour until the
patient is ambulatory.
o If the patient is neuroleptic naïve – follow parameters fro parenteral.
o The full EWS should be taken but if that is not possible then a minimum of respirations
must be recorded.
• Lying and standing BP’s
o When recording lying and standing BP’s, calculate the EWS using the lying BP. If the
patient has postural drop and the standing BP is used, it may well give a high EWS
that is not due to shock.
o The standing BP should be recorded on the chart but the other observations can be
left blank.
• Reviewing the charts
o Ensure EWS is discussed with medical staff routinely and if patient unwell.
If you feel that you need training on the taking of psychological observations, speak to your ward
manager who will arrange Trust training.
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Appendix 4 – Trustwide Early Warning Score Chart
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