ICID > Clinical Management > General Surgery > Use of the Modified Early Warning Scoring System (EWSS) and Escalation Process  
 

Use of the Modified Early Warning Scoring System (EWSS) and Escalation Process 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background

    All patients admitted to hospital have their cardio respiratory observations (TPR, BP & SpO2) monitored at regular intervals. The modified Early Warning Scoring System (EWSS) is a track and trigger scoring system that is used to monitor changes in a patient’s physiology. Patients with established or impending critical illness have their observations converted into a score; the higher the score the more abnormal the physiology. If a patient’s score reaches a certain threshold an agreed escalation protocol is followed. The aim is to help healthcare professionals determine whether a patient is improving or deteriorating. EWSS is not however a predictor of outcome nor is it a replacement for clinical judgment.

    McQuillan et al 1988 (Confidential Inquiry into Quality of Care before Admission to Intensive Care) looked at why patients admitted from a ward area were much less likely to survive intensive care than those admitted from the Emergency Department and Theatres. The study found that 41% of admissions to intensive care may have been avoidable if earlier intervention had occurred. The study also concluded that 69% of admissions to intensive care occurred late in the development of critical illness and of those 54% of admissions had sub-optimal care prior to admission.

    A similar study by Stenhouse et al (2000) reviewed the use of an Early Warning Score over a nine month period. The introduction of the system appeared to lead to earlier and timelier referral to intensive care. Both the Royal College of Surgeons and the Association of Anaesthetists of Great Britain and Ireland support the use of an EWS system. The use of EWSS’s was also a recommendation of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD 2005) and more recently in the 2007 the National Institute for Health and Clinical Excellence (NICE) clinical guideline 50, ‘Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital’.

    1.2 Aim/purpose

    Early warning scoring systems have two specific aims:

    1. To facilitate timely recognition of the patients with established or impending critical illness

    2. To empower nurses and junior medical staff to secure experienced help through the operation of a trigger threshold. When triggered, attendance by a more senior member of staff is mandatory.

    1.3 Patient/client group

    All patients admitted to hospital are considered to be at risk of developing a critical illness. It is considered good practice to commence EWSS on all patients. See section 1.4 for exceptions.

    1.4 Exceptions/ contraindications

    There are some patients in whom the use of EWSS may be inappropriate. These include:

    1. Paediatric patients

    2. Patients on the Intensive Care Unit

    3. Patients requiring no observations

    4. Patients who are terminally ill

    5. Planned discharges

    6. Where a consultant’s decision is that an EWSS score is not appropriate. In this situation this decision should be clearly documented on the front of the observation chart. An additional entry should also be made in the patient notes, recording why the decision was made not to use the EWSS.

    7. Patients in the maternity unit. They have a different observation chart, scoring system and escalation process specific to their client group.


    2. Clinical Management

    2.1 Staff & equipment

    Staff Training

    EWSS and escalation information is included in the following Trust induction strategies:

    1. Ward induction for nurses in all areas

    2. Acute Illness Management (AIM) training for year 1 foundation doctors (F1’s), nurses, midwives and physiotherapists

    3. Acute Intervention and Management at Salisbury (AIMS) training for year 2 foundation doctors (F2’s)

    4. Healthcare support workers during physiological observation training

    5. The Critical Care Outreach Team when requested can arrange additional training and updates for all ward areas and departments.

    6. As necessary, information on the use of EWSS in relation to Adverse Incidents will be highlighted to medical staff and raised at the Clinical Risk Group and Senior Nurse meetings.

    Equipment

    EWSS is incorporated into the standard observation chart (Appendix 1).

    2.2 Method/procedure

    The EWSS relies on the routine recording and charting of the physiological status of the patient. These observations include:

    1. Temperature (T)

    2. Pulse (P)

    3. Respiratory Rate (R)

    4. Blood Pressure (BP)

    5. Neurological status – (AVPU)

    6. A = Alert

      V = Responds to Voice

      P = Responds to Pain

      U = Unresponsive

    On admission to hospital the frequency should be prescribed and documented on the nursing management plan and updated as required. Physiological observations must be recorded at least every 12 hours. See section 1.4 for exceptions. Cardio respiratory parameters should be documented by the admitting medical healthcare professional in the patient’s healthcare record.

    In addition to the EWS, the patient’s oxygen saturation (SpO2) and urine output must also be assessed.

    The following action must be taken when a patient scores a 3 or more on the EWSS or triggers the oxygen saturation or urine output:

    1. The registered nurse caring for the patient should initiate observations at ½ hourly to hourly intervals together with urine output monitoring. Neurological and neurovascular observations should be considered where appropriate.

    2. The registered nurse in charge or nominated deputy must immediately review the patient and document the assessment outcomes and actions on the reverse of the observation chart.

    3. At this time the nurse in charge should consider whether further escalation is required and if not he/she should review the patient within 60 minutes.

    4. If the patient improves within this time, the medical team should be informed of the trigger and continue 2-hourly observations for a further four hours.

    5. If further escalation is required, the nurse in charge should contact the appropriate doctor. The nurse should also consider contacting the Critical Care Outreach Team if additional support and advice is needed. (At night these referrals must be made via the H@NT bleep co-ordinator). A management plan must be agreed and documented for any patient who has been reviewed.

    6. After 60 minutes if there has been no improvement an immediate senior review (SpR/ consultant) is required. At this point early referral to ITU/HDU for advice or admission would be considered.

    7. If the patient deteriorates suddenly (see table 1) fast bleep CCOT and Doctor via switchboard (dial 2222 and state your request). On arrival the nurse in charge must give a full and detailed handover using the SBAR (Situation, Background, Assessment and Recommendation) framework (see appendix 2).

    8. Following initial stabilisation the team will refer for senior help and ensure the team with overall responsibility for the patient is aware of the deterioration.

    9. All patients who are triggering and are cause for concern should be added to the Hospital at Night Handover list and discussed at the meeting.

    A flowchart can be found in appendix 3.

    Table 1:

    Airway

    • Patient is not maintaining an airway

    Breathing

    • Respiratory rate >40

    • Respiratory rate < 8

    • Sudden decrease in SpO2 <80%

    Circulation

    • Systolic blood pressure < 70 with an associated sudden decrease in conscious level

    • Heart rate < 40 with a decrease in systolic blood pressure

    • Heart rate >150 with a decrease in systolic blood pressure

    Disability

    • Sudden loss of consciousness

    Inter/intra hospital patient transfer

    It is necessary to assess a patient using the EWSS score prior to transferring them to another ward within the hospital or to an external healthcare provider. If your patient is triggering the system consider whether the patient needs to be reviewed or stabilised before transfer. If transfer is essential, refer to the Transfer Policy flow chart guidelines for personnel and equipment requirements.

    2.3 Potential complications / Risk Management

    There is the potential for the score to be inaccurate due to observations taken incorrectly or if the user has a problem with numeracy.  If the missed or inaccurate trigger caused or contributed to patient harm then this should be reported using an incident form.


    3. Patient Information


    4. Audit

    4.1 Audit Indicators

    Audit Indicator

    Exclusion

    Evidence

    Physiological monitoring - Temperature, pulse, blood pressure, respiratory rate and CNS response monitoring

    1.  The patient has a TPR chart

    Patients on the care of the dying pathway

    TPR chart

    2.   The frequency of observations is documented

    100%

    TPR chart

    Nursing management plan

    3.   There is a minimum of 12 hourly observations

    100%

    TPR chart

    4.   The documented frequency of observations is being carried out

    100%

    TPR chart

    5.   Every set of observations is scored using the Early Warning Scoring tool

    Paediatric patients

    Patients on the Intensive Care Unit

    Patients requiring no observations

    Patients who are terminally ill

    TPR chart

    6.   The score is added up correctly

    100%

    TPR chart

    7.   The entry has been signed

    100%

    TPR chart

    8.   If the EWS score is 3 or above, there is documented evidence that escalation was implemented

    100%

    Escalation record

    Healthcare record

    9.   If the EWS score is 3 or above, the frequency of observations has been increased

    Patient on the care of the dying pathway – review the need for observations

    TPR chart

    10.   If the EWS score is 3 or above, the patient has been reviewed within an agreed appropriate time scale

    Patient on the care of the dying pathway – review the need for observations

    Escalation record

    Healthcare record

    Oxygen saturation monitoring

    11.   If the patient has triggered they have been reviewed within an agreed appropriate time scale

    Patient with a medically agreed lower saturations level due to chronic lung disease.

    Escalation record

    Healthcare record

    12.   If triggered the frequency of the patient’s respiratory observations has been increased

    Patient with medically agreed lower saturations

    TPR chart

    13.   The amount of oxygen administered and the delivery system have been documented

    100%

    TPR chart

    Urine output monitoring

    14.   If the patient triggered they were reviewed within an agreed appropriate time scale

    Patient on the care of the dying

    Pathway – review the need for monitoring

    Escalation record

    Healthcare record

    15.   If triggered the frequency of the patient’s urinary observations was increased to hourly

    Patient on the care of the dying pathway – review the need for observations

    Fluid balance chart

    Nursing management plan

    4.2 Audit design

    See appendix 4

    5. Evidence Base

    1. McQuillan P, Pilkington S, Allan A et al. (1998) Confidential inquiry into quality of care before admission to intensive care.

    2. British Medical Journal. 316: 1853–8. National Confidential Enquiry into Patient Outcome and Death (2005) An acute problem?

    3. NCEPOD London Stenhouse. C, Coates S., Tivey M., Allsop P., Parker T. (2000) Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward.

    4. British Journal of Anaesthesia 2003: 84: 663 National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital: recognition of and response to acute illness of adults in hospital

    5. NICE London

    Policy Consultation Group

    • Patient Safety Steering Group members

    • Critical Care Outreach Team


    6. Appendices

    Appendix 1

    Observation Chart

     Appendix 1

    Appendix 2

    SBAR

     Appendix 2

    Appendix 3

    Flow Chart

     Appendix 3

    Appendix 4

    Audit Tool

     Appendix 4


    Document Owner Maria Ford 
    Department
    Review Date
    Document Status
    Revision Number
    1.0