1 Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration
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Guiding Framework and Policy
for the National Early Warning Score System
to Recognise and Respond to Clinical Deterioration
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Table of Contents: Page
1.0 Guiding Framework Statement 4
2.0 Purpose 5
3.0 Scope 5
4.0 Legislation/other related policies 6
5.0 Glossary of Terms and Definitions 6
6.0 Roles and Responsibilities 7
6.1 HSE 7
6.2 Regional Director of Operations/Senior managers 7
6.3 Senior management acute healthcare facility 7
6.4 Heads of Department 7
6.5 All clinical staff 7
7.0 Guideline 8
7.1 Guiding Principles 8 7.2 Essential elements 9
7.2.1 Clinical processes 9
7.2.1.1 Measurement and documentation of observations 9
7.2.1.2 Escalation of care 10
7.2.1.3 Emergency Response Systems 12
7.2.1.4 Clinical communication 13
8.0 Implementation Plan 13
8.1 Organisational supports 13
8.2 Education 14
9.0 Evaluation and Audit 15
10.0 References and Bibliography 17
11.0 Appendices 20
Appendix I Model Patient Observation Chart incorporating EWS 21
Appendix II EWS Escalation Protocol Flow Chart 24
Appendix III Pathway schema for the acutely ill patient using Acute 25
Medicine Programme Hospital Models
Appendix IV ISBAR Communication Tool 26
Appendix V National EWS and associated Education Programme –
Implementation Guide 27
Appendix VI Overview of COMPASS© training programme 30
Appendix VII Outline of recommended Audits to support implementation
Of the EWS system to recognise and respond to Clinical
Deterioration 32
Appendix VIII National Policy and Procedure for use of the an Early
Warning Score System to recognise and respond to Clinical
Deterioration (template for local adaptation) 34
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Acknowledgement: The ‘Guiding Framework and Policy for the National Early Warning Score System Policy to Recognise
and Respond to Clinical Deterioration’ has been primarily derived from the ACSQHC (2010) ‘National
Consensus Statement: essential elements for recognising and responding to clinical deterioration’,
and has been amended to suit the Irish context, with kind permission from Dr Nicola Dunbar,
Programme Manager, Recognising and Responding to Clinical Deterioration Programme, Australian
Commission on Safety and Quality in Health Care.
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1.0 Guidance Framework Statement
1.1 The Health Service Executive (HSE) is committed to the provision of safe, high quality health
services.
1.2. Patient safety and quality are central to the delivery of healthcare. The HSE, among others, is
a signatory to the 'Patient Safety First' declaration of commitment. The National Early
Warning Score and associated Education Programme for the early detection and management
of deteriorating patients is about improving outcomes for patients by improving the safety
record in our health services. The HSE in this project are committed to ensuring that adult
patients at risk of clinical deterioration in acute healthcare facilities are promptly identified
and managed according to their clinical need. 1.3 On admission to hospital, patients may be acutely unwell or, due to their clinical condition,
they may deteriorate to the extent that they may be at risk of becoming acutely ill during
their period of hospitalisation. Patients are entitled to the best possible care and need to be
confident that should their clinical condition deteriorate that they will receive prompt and
effective treatment. Early recognition of clinical deterioration, followed by prompt and
effective action, can minimise the occurrence of adverse events such as cardiac arrest, and
may mean that a lower level of intervention is required to stabilise a patient.
1.4 More recent evidence, and international experience, has identified that a systematic approach
to identification and management of the deteriorating patient can improve patient outcomes,
prevent death and reduce morbidity. Early warning scores have been developed to facilitate
early detection of deterioration by categorising a patient’s severity of illness and prompting
nursing, and other healthcare professionals, to request a medical review at specific trigger
points, utilising structured communication tools whilst following a definitive escalation plan.
1.5 This Guiding Framework defines the nationally agreed practice for recognising and responding
to clinical deterioration. The national standard scoring system for recognising clinical
deterioration of adult patients is the Early Warning Score, using the VitalPAC TM Early Warning
Score Parameters known as ViEWS. This system provides a point in time for communicating
the changes in patients’ vital signs and empowers nurses and junior doctors to take
appropriate action. It does not replace clinical judgement where staff escalate care regardless
of the score if they are concerned about a patient. The national Early Warning Score
Escalation Protocol provides guidance on the response to the deteriorating patient. Both the
ViEWS system and the escalation protocol must be implemented in acute healthcare facilities.
To achieve this, acute healthcare facilities need to have systems in place to address all the
elements in the framework.
1.6 ‘Consistent use of a single nationally agreed EWS system will ensure that all patients are
objectively assessed in the same way, regardless of the clinical expertise of the clinician or
where the patient is assessed. This will ensure that the severity of illness and the rate of
deterioration can be explicitly stated and understood throughout the entire Irish hospital
service. This will facilitate the early detection and transfer of patients who are likely to
deteriorate. The EWS will also facilitate reverse flow of stabilised patients. This should
ensure improved inter-professional communication and facilitate better and more uniform
patient care. It will also enable audit of outcomes and performance comparison between
different health care facilities’ (Report of the Acute Medicine Programme, 2010 p41, available
of the HSE website).
1.7 The National Early Warning Score and associated education programme, is a work stream of
the Acute Medicine Programme, in association with the other Clinical Programmes, Quality
and Patient Safety Directorate, Office of the Nursing and Midwifery Services Director, the Patients Representative Group, the Clinical Indemnity Scheme, the Assistant National
Director, Acute Hospital Services – Integrated Services Directorate, Irish Association of
Directors of Nursing and Midwifery (IADNAM) and Therapy Professionals Committee.
1.8 This policy directs staff towards best practice and must always be used in conjunction with
professional judgement. Each healthcare professional is individually accountable to keep up
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to date with advances in the use of the EWS, observation recording, recognition of the
deteriorating patient and must acknowledge any limitations in their own competence. Accountability is an integral part of professional practice. Practising in an accountable manner
requires a sound knowledge base upon which to make decisions in conjunction with
professional judgement. The Registered Nurse must be able to justify and document the
reason for taking a particular course of action, this includes any act or omission.
2.0 Purpose
2.1 The purpose of the Guiding Framework is to describe the elements that are essential for
prompt and reliable recognition of, and response to, clinical deterioration of patients in acute
healthcare facilities.
2.2 The Guiding Framework should guide healthcare facilities in developing recognition and
response systems tailored to their patient population, and to the resources and personnel
available.
2.3 The Guiding Framework supports; the implementation of the national standard the ViEWS
system, supporting multidisciplinary education programme COMPASS©, and the standard
communication tool ‘ISBAR’ (Identification; Situation; Background; Assessment;
Recommendation).
3.0 Scope
3.1 The Guiding Framework relates to the situation in the acute healthcare setting, where a
patient’s physiological condition is deteriorating. The general provision of care in a hospital or
other facility is outside the scope of this document.
3.2 The Guiding Framework focuses on ensuring that a track and trigger system is in place for
patients whose condition is deteriorating, and outlines the organisational supports required to
operationally progress implementation.
3.3 The Guiding Framework does not apply to patients in paediatric departments or patients in
obstetric care.
3.4 The Guiding Framework applies to all adult patients in acute healthcare facilities (obstetric
patients may have their own obstetric specific EWS) This includes:
• All inpatients on initial assessment, and as per clinical condition and clinical
treatment.
• Any outpatients/day services patients who attend acute healthcare facilities for
an invasive procedure or who receive sedation.
• All patients attending the Acute Medical Unit / Acute Medical Assessment Unit /
Medical Assessment Unit
3.5. The Guiding Framework applies to healthcare professionals and managers responsible for the development, implementation, review and audit of deteriorating patient recognition and
response systems in individual hospitals or groups of hospitals.
3.6. The Guiding Framework also applies to training and education support staff involved in the
organisation and delivery of the COMPASS© training programme.
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4.0 Legislation/other related policies
o An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and
Midwife
o An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework
o An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives
o Health Act (2004) Government of Ireland
o National Hospitals Office (2007) Code of Practice Standards for Healthcare Records
Management
o Health Service Executive (2008) Code of Practice for Integrated Discharge Planning
HSE
o Health Service Executive (2009) Framework for the Corporate and Financial
Governance of the HSE Document 1.1 (V3)
o Health Service Executive (2007) Quality and Risk Management Standard. o National Clinical Programme - Report of the National Acute Medicine 2010.
5.0 Glossary of Terms and Definitions
Acute healthcare facility: A hospital or other healthcare facility providing health care
services to patients for short periods of acute illness, injury or recovery.
Advanced life support: The preservation or restoration of life by the establishment and/or
maintenance of airway, breathing and circulation using invasive techniques such as
defibrillation, advanced airway management, intravenous access and drug therapy.
AMAU: Acute Medical Assessment Unit
AMU: Acute Medical Unit
Early warning score (EWS): An early warning scoring system is designed to measure the
patient’s routine physiological observations thus providing an indication of the overall status
of the patient’s condition and acts as a reliable indicator of impending or actual critical illness.
(Odell et al, 2002).
Emergency Response System (ERS): The Emergency Response System must be identified
in each acute hospital for daytime, out-of- hours and weekends as appropriate to the hospital
model (refer to hospital models in the Report of the National Acute Medicine Programme
(2010)).
Escalation protocol: The protocol that sets out the organisational response required for
different early warning scores identified or other observed deterioration. The protocol applies
to the care of all patients at all times. Minor local modifications may be required within the
acute hospital facility based on available resources.
HSE: Health Service Executive
ISBAR: a mnemonic to encourage consistent language and to improve multidisciplinary
communication. ISBAR correlates to:
o IDENTIFY: Identify yourself, who you are talking to and who you are talking about
o SITUATION: What is the current situation, concerns, observation and EWS.
o BACKGROUND: What is the relevant background? This helps set the scene to
interpret the situation above accurately.
o ASSESSMENT: What do you think the problem is? This requires the interpretation of
the situation and background information to make an educated conclusion about what
is going on.
o RECOMMENDATION: What do you need them to do? What do you recommend should be done to correct the current situation?
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MAU: Medical Assessment Unit
An Early Warning Score (EWS) is a bedside score and track and trigger system that is
calculated by nursing staff from the observations taken, to indicate early signs of a patient’s
deterioration. It is a valuable additional tool that will be utilised in conjunction with clinician’s
clinical judgement about the patient’s condition, to facilitate detection of a deteriorating
patient. The EWS is a multi-parameter aggregate scoring system which allows both
identification and progress monitoring of at risk patients. It includes respiratory rate, oxygen
saturations, inspired oxygen, temperature, blood pressure, heart rate, level of consciousness.
A score is attributed to each of these parameters, with one score per parameter, and the
scores are then totalled to calculate the Early Warning Score. If a score is 3 in any parameter
or an aggregate score of 3 or more is attained, then the EWS escalation protocol is activated.
An EWS does not replace the clinical judgement of the healthcare professional.
Monitoring plan: A written plan that documents the type and frequency of observations to
be recorded in the patients medical records and progress notes in the healthcare record.
Primary Medical practitioner or medical team: The treating doctor or team with primary
responsibility for caring for the patient.
Track and Trigger: A ‘track and trigger’ tool refers to an observation chart that is used to
record vital signs or observations graphically so that trends can be ‘tracked’ visually and
which incorporates a threshold (a ‘trigger’ zone) beyond which a standard set of actions is
required by health professionals if a patient’s observations breach this threshold (Clinical
Excellence Commission NSW Health (2010)).
Treatment-limiting decisions: Decisions that involve the reduction, withdrawal or
withholding of life-sustaining treatment. These may include ‘no cardiopulmonary
resuscitation’ (CPR), ‘not for resuscitation’ and ‘do not resuscitate’ orders.
6.0 Roles and responsibilities
6.1 HSE
To develop and implement a National Early Warning Score to ensure that there is a system of
care in place for the prompt identification and management of clinically deteriorating
patients.
6.2 Regional Directors of Operations/ Senior Managers
• To assign personnel with responsibility accountability and autonomy to implement the
National Early Warning Score System.
• To provide managers with support to implement the National Early Warning Score
System.
• To ensure local policies and procedures are in place in each acute health care facility
to support implementation.
• To monitor the implementation of the National Early Warning Score System support
ongoing evaluation and remedial action.
6.3 Senior management acute healthcare facility
• To provide a local governance structure to support the implementation and
ongoing evaluation of the National Early Warning Score System.
• Ensure clinical and educational staff are supported to implement the National Early
Warning Score and associated Education Programme.
• Ensure development of local policy to support the National Early Warning Score
implementation, management of the clinically deteriorating patient, and associated audit and evaluation.
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6.4 Heads of Department • To ensure all relevant staff members are aware of this Guiding Framework and
supporting policies.
• To monitor local implementation of the National Early Warning Score System,
incorporating the EWS Protocol and its outcomes.
• To ensure staff are supported to undertake the COMPASS© education programme and
related training, as appropriate to the acute healthcare facility.
6.5 All clinical staff
All Clinical staff must comply with this guiding framework and related clinical guidelines,
procedures and protocols. Each employee must adhere to their professional scope of practice
guidelines and maintain competency, in recognising and responding to patients with clinical
deterioration, including the use of the National Early Warning Score System, where this is
within their scope of practice. In using this guideline professional healthcare staff must be
aware of the role of appropriate delegation.
6.6. The national standard for recognising and responding to clinical deterioration is the ViEWS
system. The ViEWS system is a clinical assessment tool and does not replace the clinical
judgement of a qualified healthcare professional. If there are concerns regarding a patient’s
condition, staff should not hesitate in contacting a senior member of the patient’s medical
team to review the patient, irrespective of the EWS.
7.0 Guideline
7.1. Guiding Principles
7.1.1. Recognising patients whose condition is deteriorating and responding to their needs in an
appropriate and timely way are essential components of safe and high quality care.
7.1.2. Recognition and response systems must apply to all patients, in all patient care areas (as
per Section 3.3), at all times.
7.1.3. Primary responsibility for caring for the patient rests with the primary medical practitioner
or team. The utilisation of an Early Warning Score system and the EWS escalation
protocol/response system should therefore promote effective action by ward staff and the
primary medical practitioner or team, or the attending medical practitioner or team. This
includes calling for emergency assistance when required. (Emergency Response System ERS)
7.1.4. Effectively recognising and responding to deterioration requires appropriate
communication of diagnosis, including documentation of diagnosis in the healthcare
record and verbal handover. Ideally the ISBAR tool should be used, this promotes
effective communication.(appendix IV)
7.1.5. Effectively recognising and responding to deterioration requires development and
communication of plans for monitoring of observations and ongoing management of the
patient.
7.1.6. Recognition of and response to deterioration requires access to appropriately qualified,
skilled and experienced staff.
7.1.7. Recognition and response systems should encourage a positive, supportive response to
escalation of care, irrespective of circumstances or outcome.
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7.1.8. Care should be patient-focused and appropriate to the needs and wishes of the individual
and their family or carer.
7.1.9. Organisations should regularly review the effectiveness of the recognition and response systems they have in place.
7.2. Essential Elements
These elements describe the essential features of the systems of care required to implement
the National Early Warning Score System, (ViEWS) and the EWS escalation protocol, to
recognise and respond to clinical deterioration. Four elements relate to clinical processes that
need to be locally delivered, and are based on the circumstances of the facility in which care is provided (Section 7.2.1). A further three elements relate to the structural and
organisational prerequisites that are essential for recognition and response systems to
operate effectively (detailed in Sections 8.0 and 9.0).
The seven core elements to implement the National Early Warning Score System are as
follows:
Clinical processes
1. Measurement and documentation of observations
2. Escalation of care
3. Emergency Response Systems
4. Clinical communication
Organisational prerequisites
5. Organisational supports
6. Education
7. Evaluation, audit and feedback
The elements do not prescribe how this care should be delivered. Hospitals need to have
systems in place to address all elements in the Guiding Framework; however the application
of the elements in an individual healthcare facility will need to be carried out in a way that is relevant to its specific circumstances.
7.2.1 Clinical Processes
7.2.1.1. Measurement and Documentation of Observations
Measurable physiological abnormalities occur prior to adverse events such as cardiac arrest,
unanticipated admission to intensive care and unexpected death. These signs can occur both
early and late in the deterioration process. Regular measurement and documentation of
physiological observations is an essential requirement for recognising clinical deterioration.
1 Observations should be taken on all patients admitted to hospital (refer to Section 3.3
& 3.4)
2 Observations should be taken on patients at the time of admission or initial
assessment if appropriate or as per organisation guideline/protocol, and must be
documented in the patient’s healthcare record and recorded on a chart that
incorporates the National Early Warning Score System.
3 For every patient, a clear monitoring plan should then be developed and documented,
that specifies the physiological observations to be recorded and the frequency of
observations, taking into account the patient’s diagnosis and proposed treatment.
4 The frequency of observations should be consistent with the clinical situation and
history of the patient. In the hospital setting the minimum standard for the
assessment of vital signs, utilising the EWS parameters, is every 12 hours. The
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frequency of patient observations must be reconsidered and modified according to
changes in the patient’s clinical condition, and this should be documented in the monitoring plan, detailed in the medical notes and nursing care plan. This decision
should be made in collaboration between nursing staff and the medical team.
5 Physiological observations should include:
• Respiratory rate
• Oxygen saturation- SpO2
• Inspired oxygen - FiO2
• Heart rate
• Blood pressure
• Temperature
• Level of consciousness,
6 In some circumstances, and for some groups of patients, some observations will need
to be measured more or less frequently than others, and this should be specified in
the monitoring plan, and documented in the medical notes and nursing care plan.
7 The minimum physiological observations should be documented in a structured
observation chart, incorporating the National Early Warning Score System (ViEWS).
8 Patient observation charts should display physiological information in the form of a
graph. A patient observation chart should include:
• a system for tracking changes in physiological parameters over time,
• thresholds for each physiological parameter or combination of parameters that
indicate abnormality,
• information about the response or action required when thresholds for
abnormality are reached or deterioration identified,
• the key EWS parameters based on the ViEWS system as per the national EWS
Patient Observation Chart (Appendix I).
9 Clinical staff may choose to document other observations and assessments to
support timely recognition of deterioration. Examples of additional information that
may be required include; fluid balance, occurrence of seizures, pain, chest pain,
respiratory distress, Glasgow Coma Scale, pallor, capillary refill, pupil size and
reactivity, sweating, nausea and vomiting, as well as additional biochemical and
haematological analyses.
10 There are also patients in whom the use of the EWS may be inappropriate, such as
during the end stages of life and advanced palliative care. Although the majority of
patients will benefit from utilisation of EWS the clinician’s own clinical judgement dictates whether the patient will require to be regularly scored for the EWS, and how
regularly vital signs assessment is required. A note should also be made in the
patient’s healthcare record documenting why the decision was made not to use EWS.
11 When a patient is being continuously monitored using electronic technology, a full set
of vital signs must be documented on the observation chart, as per Escalation
Protocol.
7.2.1.2 Escalation of care
It is the responsibility of each acute hospital service to outline clearly their escalation protocol
for deteriorating patients at present and in the future, taking into account the
recommendations of the Acute Medicine and other relevant clinical care programmes in line
with requirements of the regulatory bodies, the Health Information and Quality Authority
(HIQA) and Clinical Indemnity Scheme (CIS).
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An escalation protocol sets out the organisational response required in dealing with different
levels of abnormal physiological measurements and observations. This response may include appropriate modifications to nursing care, increased monitoring, review by the primary
medical practitioner or team or “on call team” or calling for emergency assistance from
intensive care or other specialist teams or activate the Emergency Response System.
Primary responsibility for caring for the patient rests with the primary medical practitioner or
team. In this context, the escalation protocol describes the additional supporting actions that
must exist for the management of all patients. Although these actions should be tailored to
the circumstances of the facility, it should include some form of emergency assistance where
advanced life support can be provided to patients in a timely way. A protocol regarding
escalation of care is an essential requirement for responding appropriately to clinical
deterioration.
1 A formal documented escalation protocol is required that applies to the care of all
patients at all times. While this framework relates to Adult patients as per 3.3 & 3.4
the principles could apply to deteriorating patients in the care of Paediatric and
Obstetric services.
2 The escalation protocol should authorise and support the clinician at the bedside to
escalate care until the clinician is satisfied that an effective response has been made.
3 The escalation protocol should be tailored to the characteristics of the acute
healthcare facility, including consideration of issues such as:
• size and role (such as whether a tertiary referral centre or small community
hospital),
• location,
• available resources (such as staffing mix and skills, equipment, telemedicine
systems, external resources such as ambulances),
• potential need for transfer to another facility.
4 The escalation protocol should allow for a graded response commensurate with the level of abnormal physiological measurements, changes in physiological
measurements or other identified deterioration. The graded response should
incorporate options such as:
• increasing the frequency of observations,
• appropriate interventions from the nursing and medical staff on the ward and review
by the primary medical practitioner or team,
• obtaining emergency assistance or advice,
• transferring the patient to a higher level of care locally, or to another facility.
5 The escalation protocol should specify:
• the levels of physiological abnormality or abnormal observations at which patient
care is escalated,
• the response that is required for a particular level of physiological or observed
abnormality,
• how the care of the patient is escalated,
• the personnel that the care of the patient is escalated to, noting the responsibility of
the primary medical practitioner or team,
• who else is to be contacted when care of the patient is escalated,
• the timeframe in which a requested response should be provided,
• alternative or back up options for obtaining a response.
6 The way in which the national EWS Protocol for escalation is applied should take into
account the clinical circumstances of the patient, including both the absolute change
in physiological measurements and abnormal observations, as well as the rate of
change over time for an individual patient.
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7 The escalation protocol may specify different actions depending on the time of day or
day of the week, or for other circumstances.
8 The escalation protocol should allow for the capacity to escalate care based only on
the concern of the clinician at the bedside in the absence of other documented
abnormal physiological measurements (‘staff member worried’ criterion).
9 The escalation protocol should allow for the concerns of the patient, family or carer to
trigger an escalation of care.
10 The escalation protocol should include consideration of the needs and wishes of
patients where treatment-limiting decisions (ceilings of care) have been made.
11 The escalation protocol should be disseminated widely and included in education
programmes. On induction to an organisation all staff must be made aware of the
escalation protocol.
7.2.1.3. Emergency Response Systems (ERS)
Where severe deterioration occurs it is important to ensure that the capacity exists to obtain
appropriate emergency assistance or advice prior to the occurrence of an adverse event such
as a cardiac arrest. A deteriorated patient should activate a direct on-site response (HIQA
2011). Different models that have been used to provide this assistance include senior medical
staff, Emergency Response System (ERS), and critical care outreach (if available). The
generic name for this type of emergency assistance is ‘Emergency Response System’. The
emergency assistance provided as part of a rapid response is additional to the care provided
by attending medical personnel or primary medical team.
For most facilities, the Emergency Response System will include clinicians or teams located
within the hospital who provide emergency assistance. In some facilities the system may be
a combination of on-site and external clinicians or resources (such as the ambulance service
or local general practitioner). However comprised, and however named, an Emergency
Response System should form part of an organisation’s escalation protocol.
1 Some form of Emergency Response System should exist to ensure that specialised
and timely care is available to patients whose condition is deteriorating.
2 Criteria for triggering the Emergency Response System should be included in the
escalation protocol. Where severe deterioration occurs it is important to ensure that
the capacity exists to obtain appropriate emergency assistance or advice prior to the
occurrence of an adverse event such as a cardiac arrest.
3 The nature of the Emergency Response System needs to be appropriate to the size,
role, resources and staffing mix of the acute health care facility.
4 The clinicians providing emergency assistance as part of the Emergency Response System should:
• be available to respond within agreed timeframes,
• be able to assess the patient and provide a provisional diagnosis,
• be able to undertake appropriate initial therapeutic intervention,
• be able to stabilise and maintain the patient pending definitive disposition,
• have authority to make transfer decisions and to access other care providers
to deliver definitive care.
5 As part of the Emergency Response System there should be access, at all times, to at
least one clinician, either on-site or accessible, who can practice advanced life
support.
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6 The clinicians providing emergency assistance should have access to a medical staff
member of sufficient seniority to make treatment-limiting decisions. Where possible these decisions should be made with input from the patient, family and the primary
medical practitioner or team.
7 In cases where patients need to be transferred, to another site to receive emergency
assistance, appropriate care needs to be provided to support them until such
assistance is available.
8 When a call is made for emergency assistance, the attending medical practitioner or
team should be notified at the same time that the call has been made, and where
possible they should attend to provide relevant medical information regarding their
patient, provide support and learn from the clinicians providing assistance.
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9 All opportunities should be taken by the clinicians providing emergency assistance to
use the call as an educational opportunity for ward staff and pre-registered medical,
nursing and therapies students.
10 The clinicians providing emergency assistance should communicate in an appropriate,
detailed and structured way with the primary medical practitioner or team about the
consequences of the call, including documenting information in the healthcare record.
11 Events surrounding the call for emergency assistance and actions resulting from the call should be documented in the healthcare record and considered as part of ongoing
quality improvement processes. Records should be suitable for audit purposes.
7.2.1.4. Clinical Communication
Effective communication and team work among clinicians is an essential requirement
for recognising and responding to clinical deterioration. Poor communication at
handover and in other situations has been identified as a contributing factor to
incidents where clinical deterioration is not identified or properly managed. A number
of structured communication protocols exist that can be used for handover and as part
of ongoing patient management. The recommended communication tool for healthcare
professionals, particularly when communicating in relation to the deteriorating patient,
is ISBAR (Appendix IV).
1 Formal communication protocols should be used to improve the functioning of
teams when caring for a patient whose condition is deteriorating.
2 The value of information about possible deterioration from the patient, family
or carer should be recognised.
3 Information about deterioration should be communicated to the patient, family
or carer in a timely and ongoing way, and documented as appropriate in the
healthcare record.
8.0 Implementation Plan
8.1. Organisational supports
Recognition and response systems should be part of standard clinical practice. Nonetheless,
the introduction of new systems to optimise care of patients whose condition is deteriorating
requires organisational support and executive and clinical leadership for success and
sustainability. The acute healthcare facility should set up a EWS Committee to consider and
agree the processes and stages of implementation for the EWS system and the EWS Protocol for escalation (Appendix V).
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1 A formal policy framework regarding recognition and response systems should exist
and should include issues such as: • governance arrangements,
• roles and responsibilities,
• communication processes,
• resources for the Emergency Response System, such as staff and
equipment,
• training requirements,
• evaluation, audit and feedback processes,
• arrangements with external organisations that may be part of a rapid
response system
• Documentation regulation and management of records.
• Patient & service users
2 This policy framework should apply across the acute healthcare facility, and identify
the planned variations in the escalation protocol and responses that might exist in
different circumstances (such as for different times of day).
3 Any new recognition and response systems or procedures should be integrated into
existing organisational safety and quality systems to support their sustainability and
opportunities for organisational learning.
4 Recognition and response systems should encourage healthcare staff to react
positively to escalation of care, irrespective of circumstances or outcome.
5 Appropriate policies and documentation regarding ‘Do not Resuscitate’ decision;
treatment-limiting decisions (ceilings of care); and end-of-life decision making are
critical in ensuring that the care delivered in response to deterioration is consistent
with appropriate clinical practice and the patient’s expressed wishes.
6 A formal governance process (such as an Early Warning System Committee) should
oversee the development, implementation and ongoing review of recognition and
response systems locally. If a committee has this role, it should:
• have appropriate responsibilities delegated to it, and be accountable for its decisions
and actions,
• monitor the effectiveness of interventions and education,
• have a role in reviewing performance data, audits,
• provide advice about the allocation of resources,
• include service users, clinicians, managers and executives.
7 Organisations should have systems in place to ensure that the resources required to
provide emergency assistance (such as equipment and pharmaceuticals) are always
operational and available.
8.2. Education
Having an educated and suitability skilled and qualified workforce is essential to provide
appropriate care to patients whose condition is deteriorating. Education should provide
knowledge of observations and identification of clinical deterioration, as well as appropriate
clinical management skills. Skills such as communication and effective team work are needed
to provide appropriate care to a patient whose condition is deteriorating, and should also be part of staff development.
The education programme recommended by the HSE is the COMPASS© programme, and this
will be available to healthcare staff such as doctors, nurses and therapy professionals. The
COMPASS© programme should be delivered in full (Appendix VI). In addition, training in the
use of the patient observation chart incorporating the EWS should be facilitated.
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The training needs to be coordinated by designated staff within, or supporting, the healthcare
facility. In addition continuation of training in basic life support and professional development training in advanced life support programmes, appropriate to the clinical facility,
is advised.
1 All clinical and non-clinical staff should receive education about the local escalation
protocol relevant to their position. They should know how to call for emergency
assistance if they have any concerns about a patient, and know that they should call
under these circumstances. This information should be provided at the
commencement of employment and as part of regular refresher training.
2 All medical and nursing staff should be able to:
• systematically assess a patient,
• understand and interpret abnormal physiological parameters and other abnormal
observations,
• Understand and operationalise the National Early Warning Score system and EWS
Protocol for escalation of care,
• initiate appropriate early interventions for patients who are deteriorating,
• respond with life-sustaining measures in the event of severe or rapid deterioration,
pending the arrival of emergency assistance,
• communicate information about clinical deterioration in a structured and effective
way to the primary medical practitioner or team, to clinicians providing emergency
assistance and to patients, families and carers,
• understand the importance of, and discuss, end-of-life care planning with the
patient, family and/or carer,
• undertake tasks required to properly care for patients who are deteriorating, such as
developing a clinical management plan, writing plans and actions in the healthcare
record and organising appropriate follow up.
3 As part of the Emergency Response System competency in advanced life support
should be ensured for sufficient clinicians who provide emergency assistance to
guarantee access to these skills according to local protocols.
4 A range of methods should be used to provide the required knowledge and skills to
staff. These may include provision of information at orientation and regular refreshers
using face-to-face and online techniques, as well as simulation centre and scenario-
based training.
9.0 Evaluation and Audit
9.1 Evaluation of new systems is important to establish their efficacy and determine what
changes might be needed to optimise performance. Ongoing monitoring is necessary to track
changes in outcomes over time and to check that these systems are operating as planned.
9.2 Data should be collected and reviewed locally and over time regarding the implementation and effectiveness of recognition and response systems, namely the National Early Warning
Score system.
9.3. The National Early Warning Score and escalation of care protocol should be evaluated to
determine whether it is operating as planned. Evaluation may include checking the existence
of required documentation, policies and protocols (such as the EWS Protocol) and compliance
with policy (such as completion rates of observation charts or proportion of staff who have
received training).
9.4 Clinical audit is recommended to support the continuous quality improvement process in
relation to implementation of the national EWS system (Appendix VII). The recommended
minimum standard for audit includes:
1. Utilization of the ISBAR communication tool,
16
2. Utilization and accuracy of completion of the patient observation chart incorporating
the EWS, 3. Utilization of the ‘track and trigger’ response mechanism – the EWS Protocol.
9.5 Systems should be evaluated to determine whether they are improving the recognition of,
and response to, clinical deterioration. Evaluation may include collecting and reviewing data about
calls for emergency assistance, and adverse events such as cardiac arrests, unplanned admissions
to intensive care and hospital deaths.
9.6 The following data should be collated for each call for emergency assistance that is made to
the Emergency Response System;
• Patient demographics
• Date and time of call, response time
• Reason for the call
• The treatment or intervention required
• Outcomes of the call, including disposition of the patient.
9.7 Regular audits of triggers and outcomes should be conducted for patients who are
the subject of calls for emergency assistance. Where these data are available, this could
include longer-term outcomes for patients (such as 30 and 60 day hospital mortality).
9.8 Evaluation of the costs and potential savings associated with recognition and response
systems could also be considered.
9.10 Information about the effectiveness of the recognition and response systems may also come
from other clinical information such as incident reports, root-cause analyses, cardiac arrest
calls and death reviews. A core question for every death review should be whether the
escalation criteria for the Emergency Response System were met, and whether care was
escalated appropriately.
9.11 As part of the implementation of new systems, feedback should be obtained from frontline
staff about the barriers and enablers to change. Issues and difficulties regarding
implementation should be considered for different healthcare settings.
9.12 Consistent with any implementation process, information collected as part of ongoing
evaluation and audit should be:
• part of a feedback process to ward staff and the primary medical practitioner or
team regarding their own calls for emergency assistance
• part of a feedback process to the clinicians providing emergency assistance • reviewed to identify lessons that can improve clinical and organisational systems
• used in education and training programs
• used to track outcomes and changes in performance over time
• used to implement remedial actions
9.13 Indicators of the implementation and effectiveness of recognition and response systems
should be monitored at senior governance levels within the organisation (such as by senior
executives or relevant quality committees). It is recommended that the audit process in each
healthcare facility is overseen by the Early Warning System Committee.
9.14 It is recommended that the national EWS parameters are reviewed annually and updated as
new information becomes available either from national or international audits or research.
17
10.0 References / Bibliography
ACT Health (2007) Policy: Modified Early Warning Scores Australian Capital Territory
Directorate http://www.health.act.gov.au/compass
Avard B, McKay H, Slater N, Lamberth P, Daveson K, Mitchell I (2010) Compass ‘Pointing You
in the right direction’ Adult Training Manual. http://www.health.act.gov.au/compass
Australian Commission on Safety and Quality in Healthcare (2010) National Consensus
Statement: Essential elements for recognising and responding to clinical deterioration
ACSQHC
Bleyer AJ, et al. Longitudinal analysis of one million vital signs in patients in an
academic medical center. Resuscitation (2011), doi:10.1016/j. Resuscitation, 2011.06.033
Clinical Excellence Commission, New South Wales Health (2010) Between the flags: Keeping
patient’s safe: guidelines and implementation toolkit.
http://www.cec.health.nsw.gov.au/programs/between-the-flags Accessed 02/05/2011
Commission on Patient Safety and Quality Assurance (2008) Report of the Commission on
Patient Safety and Quality Assurance: Building a Culture of Patient Safety Department of
Health and Children
Council of International Hospitals (2007) Tactics to Manage Deteriorating Patients: Literature
Review The Advisory Board Company Washington D.C.
CREST (2007) Guidelines on the Use of Physiological Early Warning Systems Clinical
Resource Efficiency Support Team – Northern Ireland http://crestni.org.uk/
Department of Health (2009) Competencies for recognising and Responding to Acutely Ill
Patients in Hospital NHS
http://www.dh.gov.uk/en/Publicationsandstatistics/Publicationspolicyand
Guidance/DH_096989
Dellinger,RP., Levy, MM., Carlet, JM., et al (2008) Surviving Sepsis Campaign: International
Guidelines for management of severe sepsis and septic shock Critical Care Medicine 36: 296
– 327 http://www.survivingsepsis.com/implement/resources/guidelines
Gao, H., McDonnell, A., Harrison, D.A. et al (2007) Systematic review and evaluation of
physiological track and trigger warning systems for identifying at risk patients on the ward.
Intensive Care Medicine. 33:667-79
Health Information and Quality Authority (2011) Report of the investigation into the quality
and safety of service and supporting arrangements provided by the Health Service Executive
at Mallow General Hospital http://www.hiqa.ie/
Health Information and Quality Authority (2010) Guidance on Development of Key
Performance Indicators and Minimum Data Sets to monitor Healthcare Quality
Health Service Executive (2011) Training Manual for the National Early Warning Score and
associated Education Programme
Health Service Executive (2010) Achieving excellence in clinical governance: Towards a
culture of accountability Quality and Clinical Care Directorate
Health Service Executive (2009) Towards excellence in clinical governance – a Framework for
Integrated Quality, Safety and Risk management across HSE Service providers Framework
Document Version 1
18
HSE Cavan & Monaghan, Louth/Meath Hospitals HSE DNE (2008) Guideline for Vital Signs
Assessment of Adults and the use of the Physiological Track and Trigger System ‘POTTS’
HSE Mid Western Regional Hospital (2010) Guideline for Vital Signs Assessment of Adults
and the use of the Simple Clinical Score (SCS) Assessment Tool and the HOTEL Monitoring
Score
HSE South Tipperary General Hospital (2009) Modified Early Warning Scoring System:
Guidelines for staff
HSE Waterford Regional Hospital (2011) Guidelines for Healthcare staff in the use of a
Modified Early Warning Score (EWS)
James Connolly Hospital Blanchardstown (2011) Guideline for use of the Early Warning Score
in Connolly Hospital
Kellett J & Kim A. Validation of an abbreviated VitalpacTM Early Warning Score
(ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital. Resuscitation (2011), doi:10.1016/j.resuscitation.2011.08.022
National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital:
Recognition of and response to acute illness in adults in hospital. NHS: NICE
www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf
National Institute for Health and Clinical Excellence (2010) Review of Clinical Guideline
(CG50) Acutely Ill patients in hospital NHS: NICE
http://www.nice.org.uk/nicemedia/live/11810/52356/52356.pdf
National Institute for Health and Clinical Excellence (2007) Audit Criteria: Acutely Ill patients
in hospital (NICE clinical guideline 50) NHS: NICE
National Institute for Clinical Excellence/ Commission for Health Improvement (2002)
Principles for Best Practice in Clinical Audit Oxon: Radcliffe Medical Press
National Patient Safety Agency (2007) Recognising and responding appropriately to early
signs of deterioration in hospitalised patients NHS www.npsa.nhs.uk
New South Wales (NSW) Health (2010) Policy Directive: recognition and Management of a
Patient who is Clinically Deteriorating http://www.health.nsw.gov.au/policies/
New South Wales (NSW) Health (2010) Standard: Recognition and management of Patients
who are Clinically Deteriorating http://www.health.nsw.gov.au/policies/
Patient Safety First (2008) The ‘How to Guide’ for Reducing Harm from Deterioration NHS www.patientsafetyfirst.nhs.uk
Perbedy MA, Cretikos M, Abella BS, De Vita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ,
Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L (2007)
Recommended Guidelines for Monitoring, Reporting and Conducting Research on Medical
Emergency Team, Outreach and Rapid Response Systems: An Uystein-Style Scientific
Statement : A Scientific statement from the International Liaison Committee on Resuscitation
( American Heart Association, Australian Resuscitation Council, European Resuscitation
Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation,
Resuscitation Council of Southern Africa, and the New Zealand Resuscitation Council); the
American Heart Association Emergency Cardiovascular Care Committee; the Council on
Cardiopulmonary,Perioperative, and Critical Care; and the Interdisciplinary Working Group on
Quality of Care and Outcomes Research Circulation 116: 2481-2500.
19
Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS — Towards a
National early warning score for detecting adult inpatient deterioration. Resuscitation 2010;81:932–7.
Royal College of Physicians of Ireland, Irish Association of Directors of Nursing and Midwifery,
Therapy professions Committee, Quality and Clinical Care Directorate, Health Service
Executive (2010) Report of the National Acute Medicine Programme
http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf
20
11. 0 APPENDICES Section
21
APPENDIX 1.Model of PATIENT OBSERVATION CHART(A3 format folded to A4 -
punched for insertion to patient’s record).
Table 1. Front Page
22
Table 2. Middle Pages (Patient Observation Chart)
23
Table 3. Back Page (Patient Observation Chart)
NOTE: The scoring parameters for the physiological signs identified in the nationally agreed Early Warning Score (ViEWS) in Table 1, must be strictly adhered to in
the event that an acute hospital decides to design other aspects of their own
observation chart.
24
APPENDIX 11: EWS PROTOCOL (Escalation Flow Chart)
25
APPENDIX III: Pathway schema for the acutely ill patient using Acute
Medicine Programmes Hospital Models
The Acute Medicine Programme has just commenced the implementation phase. Along with other
programmes, it will take some time before the recommendations are embedded in the system.
Regional arrangements are taking place to categorise hospitals into Models e.g. Model 2, 3 or 4.
It is the responsibility of each acute hospital service to outline clearly their escalation protocol for
deteriorating patients at present and in the future taking into account the recommendations of the
Acute Medicine, Elective Surgery, Emergency Medicine and Critical Care Programmes in line with
requirements of the regulatory body, the Health Information and Quality Authority (HIQA).
A pathway schema has been identified for the acutely ill patient in the hospital system using Acute
Medicine Programme Hospital Models to clarify a concern about the appropriate response to the
patient with severe deterioration detected by an Early Warning Score. An Early Warning Score
detects the deterioration and triggers the appropriate response for the deteriorated patient, as
follows-
1. Model 2 Hospitals: The differentiated patient admitted to a Model 2 Hospital is not acutely ill on admission, has no propensity to deteriorate and has no complex specialty needs requiring bypass or
transfer. A differentiated patient may be admitted for other reasons- e.g. not for escalation or
resuscitation care. There is no expectation the patient admitted to a Model 2 Hospital will require or
receive immediate acute hospital critical care. However, the admitted differentiated patient may
undergo gradual or abrupt severe deterioration detected by an Early Warning Score activating an
on-site appropriate care response.
2. Model 3 or Model 4 acute Hospitals: The undifferentiated acutely ill patient admitted to a
Model 3 or 4 acute Hospital may undergo gradual or abrupt severe deterioration detected by an
Early Warning Score activating an on-site 24/7/365 emergency resuscitation response. This is
consistent with the recent HIQA Recommendation SOC1.
Both these deteriorations are detected equally well by an Early Warning Score but with different expectations. This distinction, is a strength of Acute Medicine Programme Hospital Models.
(Contributed by the Critical Care Programme).
Complex
regional/supra-regional specialty
needs
Severe illness, multi/neuro-trauma-
bypass/transfer protocol,
Acutely ill patient with a propensity to
deteriorate
No expectation of immediate
resuscitation or critical care
response
26
APPENDIX IV: ISBAR COMMUNICATION TOOL
ISBAR
IDENTIFY – Identify yourself, who you are talking to and who you are talking about
SITUATION – What is the current situation, concerns, observations, EWS. BACKGROUND – What is the relevant background. This helps to set the scene to interpret the situation above accurately ASSESSMENT – What do you think the problem is ? This requires the interpretation of the situation and background information to make an educated conclusion about what is going on. RECOMMENDATION – What do you need them to do ? What do you recommend should be done to correct the current situation ?
Text box 1. Adapted from COMPASS© programme
27
APPENDIX V
The National Early Warning Score and associated
Education Programme (Compass)
Implementation Guide
28
PTO
Adapted from ACT Health model
Proposed Group – to oversee implementation & evaluation on the site Senior Medical, Nursing, Audit, Quality & Risk, Education Personnel, Therapy Professional, Hospital Manager, Practice Development,
Consult widely
Decide on EWS observation chart to suit local needs – ranges for observations must remain the same as per nationally agreed EWS
Set up sub-group to work on this
Organise leadership & change management session for staff as appropriate- National Leadership & Innovation Centre (ONMSD)
Develop local examples for training
Depts/ Units
Consultants NCHD’s
Hospital management
Therapies, Audit, Quality & Risk personnel, Practice Development
Aim for Implementation of EWS Observation Chart one month following initial training when 50% of staff are trained in an area.
Feedback to clinical areas
Make materials available. (Identify website link)
Distribute manuals, & CD’s, sample obs. Chart, quiz questions as appropriate Allow time for e-learning as appropriate
Set up EWS project group
Agree timelines for implementation
Confirm initial departments/units for implementation
Develop & approve EWS policy for hospital - incl. escalation pathway policy, audit trail and training
Identify staff for Train the Trainer programme, e.g. Medical, BLS, ACLS, ALERT, Practice Development, CNME staff
Training, Implementation, Audit and Evaluation Stage
Conduct Train the Trainer sessions
Organise staged rollout in Hospital
Identify lead person/s to co-ordinate and lead EWS
project in acute hospital
Planning Stage
NB - Doctors need to be part of the training group to provide training for medical staff on site
29
Adapted from ACT Government, Australia, Health model
Schedule training sessions
Communicate log in details to staff for e-learning section as required
Interactive CD Training manual
Quiz to be completed and submitted to trainers 2 days in advance of training
Book participants for each session
Check quiz results
Conduct training
Provide certificate Conduct evaluation of education
Prepare ward posters as appropriate e.g. ISBAR, Flow charts, Escalation policy etc
Introduce EWS obs chart when at least 50% of staff each ward/area have received training
Conduct observation chart audits one month post introduction agree regular audit schedule thereafterregularly
Evaluate outcomes. Create action plans for improvement
30
APPENDIX VI: COMPASS© TRAINING PROGRAMME
Compass is a multidisciplinary education program designed to enhance our understanding of
patients deteriorating and the significance of altered observations. It also seeks to improve
communication between health care professions and enhance timely management of patients.
Programme Learning Outcomes
On completing the COMPASS education programme the learner will knowledgeable in the recognition
and management of clinically deteriorating patients.
They will be able to utilise their skills and competencies to provide supportive symptom management
until a definitive diagnosis has been made and treatment initiated.
Aims and Objectives
1. Prioritise Care, using
• Clinical judgement - apply prior and acquired knowledge to enable early recognition of the
deteriorating patient
• Decision making skills
• Guidelines and algorithms
• Initiate an appropriate and timely response.
2. Show Clinical Reasoning
• Recognise, interpret and act on abnormal clinical observations e.g. escalate care as
appropriate
• Understand the importance and relevance of clinical observations and the underlying
physiology
• Interpret results of investigations
• Recognise own limitations
3. Appropriate referral of patients
• Assess severity of illness
• Recognise the need for specialist assistance
• Identify the most appropriate environment for the patient
4. Use evidence based medicine
• Utilise most recent scientific evidence agreed with health care colleagues
• Work within local and national guidelines and protocols
•
5. Improve communication and team working:
• Promote the use of more focussed communication between healthcare professionals
• Communicate the patient status effectively with colleagues (to the right people at the right
time)
• Facilitate teamwork within the multi-disciplinary team for enhanced patient outcomes
• Develop and action management plans for patients in conjunction with colleagues.
How it Works
There are three phases to the package to be completed in the following order:
• The CD and manual to be worked through independently
• A multiple choice quiz
• A face to face session
31
Details of the COMPASS training programme are available on the HSE website: www.hse.ie
Acknowledgement: The COMPASS programme has been modified to suit the Irish healthcare system
with the kind permission of the Health Directorate, ACT Government, Australia.
32
APPENDIX VII:
Outline of recommended audits to support implementation of the EWS
system to recognise and respond to clinical deterioration
The EWS audit process is recommended to be undertaken from a multidisciplinary perspective where
appropriate.
The minimum requirement for clinical audit of the EWS system in each acute healthcare facility is
as follows:
A. Measure 3 elements of the EWS system–
1. Utilization of ISBAR communication tool – simple ISBAR tool and audit document
2. Utilization and accuracy of completion of EWS Patient Observation Chart
3. Utilization of track and trigger response mechanism to be completed for all patients
who trigger EWS
B. In addition to the minimum requirement for audit the following may be utilised to evaluate
the effectiveness and of the EWS system locally, and to support the implementation and
sustainability of the EWS system, as appropriate, according to local resources and expertise.
The list provided is not exhaustive:
1. Measure patient outcomes and thus the effectiveness of the system
Log of all patients (healthcare record number) with details triggering EWS system:
EWS / Emergency Response System call log. In this way each hospital will be able to
track:
- Frequency of utilization
- Appropriateness of utilization
- Physiologic indicators which triggered the system (triggering events)
2. Disposition of patients triggering a response - No change in location/transfer to non ICU location/ transfer ICU/HDU /PACU /CCU /
Stroke unit
- Transfer out of hospital
3. Scope of care decisions – ‘Do Not Resuscitate’ or palliative care order
4. Patient outcomes
- Alive/died
- Non DNR cardiac arrests/1,000 discharges – proportion surviving
cardiopulmonary arrest-day of arrest/30days/180days after /deaths/
1,000discharges
- Non DNR deaths/1,000 discharges
- Unplanned ICU admissions/1,000 discharges
- Median and mean Length of ward/ICU /hospital stay.
- Capture patients who did not trigger EWS/ Emergency Response System call and
who
should have triggered a response
- Review Risk Management complaints/clinical indemnity: failure to
recognise and treat/ unexpected ICU admissions, times of
admission to ICU/examine log of all hospital deaths/cardiac
arrest databases/report from staff
- Outcomes before and after EWS introduction: Review number
of ICU admissions before and after especially unexpected
admissions / hospital deaths / cardiac arrest calls.
C. Training audit
- Audit of Compass© training – training evaluation record
- Database of staff trained - each hospital to make local arrangement
33
D. Staff evaluation of the system
- Should include questions to elicit knowledge and awareness of the system - Should elicit feedback re user friendliness of observation chart
- Consider focus groups:
To include nurses/consultants /NCHDs/ therapy professionals.
E. Resources
Review equipment and resource factors:
-availability of higher dependency beds, personnel and equipment available at a local level.
34
APPENDIX VIII
National Policy and Procedure
for the use of the
Early Warning Score System
to recognise and respond to clinical deterioration
(template for local adaptation)
Document
reference number
Document Developed by: National Governance Group for EWS
Revision number
Document approved by:
Approval date:
Responsibility for implementation: All healthcare staff
Revision date:
Responsibility for review and audit: Recommend local EWS Committee
35
Table of Contents:
1.0 Policy Statement ..
2.0 Purpose ..
3.0 Scope ..
4.0 Legislation/other related policies ..
5.0 Glossary of Terms and Definitions ..
6.0 Roles and Responsibilities ..
7.0 Procedure ..
7.1 Vital signs assessment ..
7.2 Early warning score ..
7.3 EWS Protocol for Escalation of Treatment ..
7.4 Procedure for communication in relation to the
deteriorating patient ..
8.0 Implementation Plan ..
9.0 Evaluation and Audit ..
10.0 References / Bibliography ..
11.0 Appendices
Appendix I Model Patient Observation Chart incorporating EWS ..
Appendix II EWS Escalation Protocol ..
Appendix IV Signature Sheet ..
Disclaimer: The information contained within this policy is the most accurate and up to date, at date of approval. The policy contains a procedural guideline for
local adaptation and it is the responsibility of the local organisation to update this guideline, according to best practice.
36
1.0 Policy Statement
1.1. This policy supports the implementation of the Health Service Executive (2011)
Guiding Framework for the use of a National Early Warning Score System to recognise
and respond to clinical deterioration
1.2. (Name of hospital /Health Service Executive) is committed to ensuring that patients at
risk of clinical deterioration are promptly identified and managed according to their
clinical need.
1.3. Patients admitted to (name of hospital /Health Service Executive) are entitled to the best possible care and need to be confident that should their clinical condition
deteriorate that they will receive prompt and effective treatment.
1.4. The purpose of this policy is to ensure a standardised approach to the use of a track
and trigger system, utilising the National Early Warning System (ViEWS) and Early
Warning Score escalation protocol.
1.5. The national standard for recognising and responding to clinical deterioration is the
Early Warning Score, using the VitalPAC Early Warning Score Parameters known as
the ViEWS system.
1.6. All healthcare staff must apply the National Early Warning Score system using ViEWS
parameters and EWS Protocol for escalation, as outlined in this policy, with minor
modifications to the escalation protocol, if appropriate, for individual acute hospital
sites.
2.0 Purpose
2.1 To improve patient outcomes by detecting and acting upon early signs of deterioration
in patients. This will in part be achieved through the implementation of the Early
Warning Score ( EWS) system that:
• Identifies trends in patient vital signs observations
• Ensures that timely patient review and appropriate treatment occurs; and
• Improves the documentation and communication of patient observations.
2.2. To provide clinical staff with clear guidelines on the measurement of EWS vital signs
and the escalation and communication of triggered Early Warning Scores to the
appropriate medical personnel.
3.0 Scope
3.1 This policy applies to all patients in acute care facilities (name of HSE hospital). This
includes:
• All inpatients on initial assessment, and as per clinical condition and clinical
treatment.
• Any outpatients/day services patients who attend acute healthcare facilities for
an invasive procedure or who receive sedation. • All patients attending the Acute Medical Unit / Acute Medical Assessment Unit /
Medical Assessment Unit
3.2. This policy does not apply to patients in paediatric departments or in obstetric care.
37
3.3. It applies to clinicians and managers responsible for the development, implementation
and review of the National Early Warning Score System in (name of hospital /Health Service Executive).
3.5 The policy also applies to training and education of support staff involved in delivery of
the COMPASS© education programme.
4 Legislation/other related policies
• Health Service Executive (2011) A Guiding Framework for the use of an Early Warning Score System to recognise and respond to clinical deterioration
• An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and
Midwife
• An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework
• An Bord Altranais (2002) Recording Clinical Practice Guidance to Nurses and Midwives • Data Protection Act (2003)
• HSE (2008) Code of Practice for Integrated Discharge Planning
• NHO (2007) Code of Practice Standards for Healthcare Records Management
• Local Haemovigilance policies
• Local Resuscitation policies
• Local ‘Do Not Resuscitate’ policies
• Local medication management policies relating to Patient Controlled Analgesia; spinal/
epidural anaesthesia, opioid administration.
• Local infection prevention and control policies
5 Glossary of Terms and Definitions
Acute healthcare facility: A hospital or other healthcare facility providing health care
services to patients for short periods of acute illness, injury or recovery.
Advanced life support: The preservation or restoration of life by the establishment and/or
maintenance of airway, breathing and circulation using invasive techniques such as
defibrillation, advanced airway management, intravenous access and drug therapy.
AMAU: Acute Medical Assessment Unit
AMU: Acute Medical Unit
Early warning score (EWS): An early warning scoring system is designed to measure the
patient’s routine physiological observations thus providing an indication of the overall status
of the patient’s condition and acts as a reliable indicator of impending or actual critical illness.
(Odell et al, 2002).
Emergency Response System (ERS): The Emergency Response System must be identified
in each acute hospital for daytime, out of hours, weekends as appropriate to the hospital
model (refer to hospital models in the Report of the National Acute Medicine Programme,
2010).
Escalation protocol: The protocol that sets out the organisational response required for
different early warning scores identified or other observed deterioration. The protocol applies
to the care of all patients at all times. Minor local modifications may be required based on
available resources.
HSE: Health Service Executive
38
ISBAR: a mnemonic to encourage consistent language and to improve multidisciplinary
communication. ISBAR correlates to: o IDENTIFY: Identify yourself, who you are talking to and who you are talking about
o SITUATION: What is the current situation, concerns, observation, EWS.
o BACKGROUND: What is the relevant background? This helps set the scene to
interpret the situation above accurately.
o ASSESSMENT: What do you think the problem is? This requires the interpretation of
the situation and background information to make an educated conclusion about what
is going on.
o RECOMMENDATION: What do you need them to do? What do you recommend
should be done to correct the current situation?
MAU: Medical Assessment Unit
An Early Warning Score (EWS) is a bedside score and track and trigger system that is
calculated by nursing staff from the observations taken, to indicate early signs of a patient’s
deterioration. It is a valuable additional tool that will be utilised in conjunction with clinician’s
clinical judgement about the patient’s condition, to facilitate detection of a deteriorating
patient. The EWS is a multi-parameter aggregate scoring system which allows both
identification and progress monitoring of at risk patients. It includes respiratory rate, oxygen
saturations, inspired oxygen, temperature, blood pressure, heart rate, level of consciousness.
A score is attributed to each of these parameters, with one score per parameter, and the
scores are then totalled to calculate the Early Warning Score. If a score is 3 in any parameter
or an aggregate score of 3 or more is attained the EWS protocol is activated.
An EWS does not replace the clinical judgement of the healthcare professional.
Monitoring plan: A written plan that documents the type and frequency of observations to
be recorded in the patients medical records and progress notes in the healthcare record.
Primary Medical practitioner or medical team: The treating doctor or team with primary
responsibility for caring for the patient.
Track and Trigger: A ‘track and trigger’ tool refers to an observation chart that is used to
record vital signs or observations graphically so that trends can be ‘tracked’ visually and
which incorporates a threshold (a ‘trigger’ zone) beyond which a standard set of actions is
required by health professionals if a patient’s observations breach this threshold (Clinical
Excellence Commission NSW Health (2010)).
Treatment-limiting decisions: Decisions that involve the reduction, withdrawal or
withholding of life-sustaining treatment. These may include ‘no cardiopulmonary resuscitation’ (CPR), ‘not for resuscitation’ and ‘do not resuscitate’ orders.
6.0 Roles and responsibilities
6.1. All healthcare staff must comply with this policy.
6.2. Key roles and responsibilities are outlined in the HSE (2011) Guiding Framework for the use
of an Early Warning Score System to recognise and respond to clinical deterioration for
guidance.
6.3. The EWS system is a physiological ‘track and trigger’ clinical assessment tool and cannot
replace the clinical judgement of a qualified member of staff. If there are concerns regarding
a patient’s condition, nursing/therapy professionals/medical staff should not hesitate in
contacting a senior member of the patient’s medical team to review the patient, irrespective
of the EWS.
7.0 Procedure
39
7.1. Vital signs assessment
7.1.1 The minimum vital signs to be recorded with each set of vital signs include:
• respiratory rate
• oxygen saturations (SpO2)
• heart rate
• blood pressure
• temperature
• level of consciousness and
• inspired oxygen (if appropriate) FiO2
7.1.2 Other specific observations pertaining to adult patients are outlined in Sections 7.2.9 and 7.2.11.
7.1.3. A clear monitoring plan needs to be documented on each patient including the frequency of
observations, taking into account the patient’s diagnosis and proposed treatment. This should
be decided in consultation between nursing, medical staff and therapy professionals as
appropriate.
7.1.4. The patient’s diagnosis, the presence of co-morbidities and the treatment plan for the patient
must be taken into account when determining the frequency of observations. Certain patients
require more regular observations in the acute setting as per clinical condition and protocol
7.1.5. A full set of vital signs should be documented on all patients at the following times:
• On admission and at time of initial assessment
• Postoperatively as per local protocols
• Post procedure as ordered
• Minimum of 4/24 for 24 hours on any patient admitted from the Emergency
Department or Acute Medical Unit /Acute Medical Assessment Unit / Medical
Assessment Unit or transferred from a critical care area (e.g. Intensive Care Unit,
Coronary Care Unit, High Dependency Unit) or following an inter hospital transfer
• Minimum of every 12 hours on all patients unless otherwise specified
In addition :
• As directed by the medical team
• If the patient’s condition deteriorates
• Family member or carer concern, as appropriate
• As per EWS Escalation Protocol (Appendix II)
• As per other standard operating procedures (e.g. blood transfusion, Patient Controlled
Analgesia (PCA), Epidural/Spinal analgesia /infusions and Intravenous/Subcutaneous
Opioid Infusions)
• Following administration of an opioid other than listed above.
• Prior to administration of medications that will directly affect the vital signs (e.g.
cardiac medications).
7.1.5. If a single parameter is rechecked to assess the effect of an intervention (i.e. oxygen
saturation if oxygen has been applied, or temperature) a full set of vital signs should be done
within 30 minutes.
7.1.6. The vital signs are to be documented on the relevant observation chart, the design of which
should be based on the national EWS model Patient Observation Chart template, and must
include the national EWS parameters, as outlines in the model chart (Appendix I).
7.1.7. Any decrease in frequency of vital sign measurement must only be done on the direction
of the CNM/nurse-in-charge in consultation with the medical practitioner and must be documented in the patient’s healthcare record.
40
7.1.8 Where a patient has an Early Warning Score of 3, nursing staff should increase the minimum
observation frequency to 4 hourly, alert the nurse in charge and team / on-call SHO. The
SHO should review the patient within 1 hour and/or escalating care if determined by patient
need and/or clinical judgement. (A Score of 2 Heart Rate ≤ 40 (bradycardia) requires the
nurse to do half hourly observations, alert the nurse in charge and the team/on-call SHO.
The SHO should review immediately).
7.2. Early Warning Score
7.2.1. The EWS is to be applied when patient observations are taken (Section 7.1).
7.2.2. An Early Warning score is to be calculated each time a set of observations is taken.
Observations to be scored include:
• respiratory rate
• oxygen saturation
• inspired oxygen (Fi02)
• blood pressure
• pulse
• temperature,
• level of consciousness: AVPU
• All observations require scoring if they fall on a coloured area of the chart. Enter a
score for each observation (including zeros) in the relevant box. Add up the score for each observation: (Respiratory Rate, SpO2 Rate, Pulse Rate, Blood Pressure, Temperature, and
AVPU, and in addition include the score for inspired oxygen (Fi02), if appropriate. This
equates to the total Early Warning Score (EWS). Review the EWS score in line with the EWS
Protocol for escalation (Appendix II).
7.2.3. The EWS may track higher scores because of individual patient’s pre-existing conditions (e.g.
chronic lung disease, dialysis patients). This should be noted in the patient’s management
plan.
7.2.4. The initial frequency of the EWS calculation and vital signs assessment, appropriate to clinical
need, is determined by the registered nurse in collaboration with the medical team, and in
view of the EWS Escalation Protocol. This must be documented in the patient’s healthcare
record, and communicated in the nursing notes.
7.2.5. The blood pressure score of 111 – 249 attracts a score of 0. The BP range is weighted
based on the ViEWS Research (Prytherch & Smith et al 2010). It doesn't mean that extreme
BPs are unimportant and do not need a doctor's involvement - just as the fact that a nurse is
‘merely’ worried about a patient should not exclude a review. Where a patient has a systolic
blood pressure of greater than or equal to 200 mm/Hg they should be reviewed by a doctor.
7.2.5.4. There may be times when the usual SBP may change for a patient during the admission
(e.g. started on an antihypertensive). If this occurs the time and date of the change and
the reason for the change should be documented in the clinical record.
7.2.5.5. Lying and Standing Blood Pressure: For patients who require lying and standing blood
pressure, chart both on the EWS chart and label accordingly.
7.2.5.6. Note: A manual reading should be obtained if the automated blood pressure reading is
outside the patient’s usual range (high or low), if known, or if the patient has an irregular
heart rate. If the electronic reading does not measure on the second attempt use a manual cuff.
41
7.2.7. Level of consciousness is assessed in the EWS by using the AVPU score - Is the patient
Alert; Responding to Verbal Stimulus; Responding to Painful Stimulus; Unresponsive (AVPU)) (Note that neurological deterioration is the second most important marker of acute
deterioration in acutely ill patients). All patients who present with a possible neurological
pathology or any suspicion of Meningococcal disease should have Glasgow Coma Scale vital
signs undertaken in conjunction with the EWS. A supplemental neurological observations
chart may be used alongside the patient observation chart to record the Glasgow Coma Scale
(GCS).
7.2.8. There are also patients in whom the use of EWS may be inappropriate, such as during the
end stages of life, advanced palliative care. Although the majority of patients will benefit from
utilisation of EWS the clinicians own clinical judgement dictates whether s/he requires the
patient to be regularly scored. Where a Consultant’s decision is that a EWS score is not
appropriate then this should be clearly written onto the front of the observation chart. An
annotation should also be made in the patient’s healthcare record documenting why the
decision was made not to use EWS.
Additional observations:
7.2.9. All patients require urinalysis and weight recorded on admission. These should be repeated as
clinically indicated.
7.2.10. The assessment of pain should be recorded routinely, if appropriate and as clinically
indicated. The type of pain assessment tool and chart may be decided locally.
7.2.11 The vital signs assessment triggers (refer to Section 7.2) for the EWS do not detail the
specific physiological parameters for the early detection of sepsis. However, the escalation
protocol prompts consideration of Sepsis where the following signs are present:
Temperature > 38C or < 36C, Respiratory Rate > 20 bpm, or PaCO2 < 4.3 KPa, Heart Rate
> 90 bpm , White blood cell count > 12 or < 4, this information is outlined on the front of the
Observation Chart, with appropriate actions recommended. (Appendix 1)
7.2.12 When a patient is being continuously monitored using electronic technology, a full set of vital
signs must be documented on the observation chart, as per Escalation Protocol.
7.3. EWS Protocol for Escalation of Treatment
7.3.1. The purpose of the Early Warning Score is to support clinical staff in monitoring the condition
of patients and to improve communication with the medical team so that an appropriate
treatment plan can be promptly implemented for the patient.
Once a patient has an Early Warning Score of 3 in any parameter or an aggregate score of 3
or greater than 3 the EWS Escalation Protocol (Appendix II) must be adhered to. ( A Score of
2 HR ≤ 40 Bradycardia requires the nurse to do half hourly observations, alert the nurse in
charge and the team/on-call SHO. The SHO should review immediately.
7.3.2. Trigger score: a total EWS of 1-2 is the trigger point for Nurse in Charge review as per EWS
protocol, with escalated notification at EWS 3 to ≥ 7. If the EWS is 3 in any single
parameter; or a Score of 2 HR ≤ 40 (bradycardia); or if the patient is not improving, a senior doctor should review the patient.
7.3.3. Any patient with a EWS of 3 or above should have a clearly documented monitoring plan
which includes required frequency of observations and Early Warning Scoring, and agreed
parameters for review, if different from those stated in the escalation protocol. This must be
written in the patient’s healthcare record.
7.3.4. If a medical review is not received within the specified time period, the medical team should
be reminded. If response is not carried out as per EWS Escalation Protocol the CNM/Nurse-in
–charge is advised to document and contact the Registrar or Consultant. This also should be
42
reported to Senior Nursing Management as appropriate and clinical risk management using
appropriate reporting mechanism.
7.3.6. The EWS system is a clinical assessment tool and does not replace the clinical judgement of a
qualified healthcare professional. If there are concerns regarding a patient’s condition, staff
should not hesitate in contacting a senior member of the patient’s medical team to review the
patient, irrespective of the EWS.
7.3.7. (Refer also to HSE (2011) A Guiding Framework for the use of The National Early Warning
Score System to Recognise and Respond to Clinical Deterioration for further guidance).
7.4. Procedure for Communication in relation to the deteriorating patient
7.4.1. The recommended procedure for effective verbal communication between clinical staff, about
the deteriorating patient, is to utilise the Identify, Situation, Background, Assessment and
Recommendation (ISBAR) technique in delivering communication (Text box 1.). On
contacting the doctor the nurse must provide information on the reason for the elevated
score, current vital signs, recent procedures undergone by the patient. A record of this
communication should be recorded in the patient’s healthcare record including who was
contacted, by name, and at what time (Appendix III).
7.4.2. Appropriate documentation must be maintained and updated in the patient’s healthcare
record, to support continuity of care and transfer of essential communications relating to the
patients condition and treatment. This includes the patients monitoring and management
plan. Once a patient is reviewed a clear medical plan must be documented and
communicated to nursing staff looking after the patient. This also must be recorded in the
patient healthcare record.
ISBAR
IDENTIFY – Identify yourself, who you are talking to and who you are talking about
SITUATION – What is the current situation, concerns, observations, EWS etc
BACKGROUND – What is the relevant background. This helps to set the scene to
interpret the situation above accurately
ASSESSMENT – What do you think the problem is ? This requires the interpretation
of the situation and background information to make an educated
conclusion about what is going on.
RECOMMENDATION – What do you need them to do ? What do you recommend should be
done to correct the current situation ?
Text box 1.
7.4.3. When documenting a medical entry always document:
H – History
E – Examination
I – Impression/diagnosis
P – Management plan
7.4.4. Management plans should include:
• Observation orders – specification of the frequency of observations
• Nursing orders – detail of more intensive monitoring etc
43
• Therapy professions orders
• Change in therapy orders • Investigations/intervention orders
• Notification orders – guidance for when to call team if there are concerns
7.4.4. Appropriate handover of information pertaining to the clinically deteriorating patient,
including EWS scores, must be made at shift handover.
7.4.5. The EWS Patient Observation chart is for continuous use during a patient admission period.
If the patient is transferred to another ward the chart must be continued in use. It should be
filed in the patient healthcare record when completely filled or on discharge.
7.4.6. (For further information refer to the HSE (2011) Guiding Framework for the use of an Early
Warning Score System to recognise and respond to clinical deterioration).
8.0. Implementation Plan Key actions for implementation to be followed as per in the HSE (2011) Guiding Framework
for the use of an Early Warning Score System to recognise and respond to clinical
deterioration.
Specific detail on implementation locally is to be outlined.
9.0 Evaluation and Audit Key actions for evaluation and audit to be followed as per in the HSE (2011) Guiding
Framework for the use of an Early Warning Score System to recognise and respond to clinical
deterioration.
Specific detail on implementation locally is to be outlined.
44
10.0 References/Bibliography
ACT Health (2007) Policy: Modified Early Warning Scores Australian Capital Territory
Directorate http://www.health.act.gov.au/compass
Avard B, McKay H, Slater N, Lamberth P, Daveson K, Mitchell I (2010) Compass ‘Pointing You
in the right direction’ Adult Training Manual. http://www.health.act.gov.au/compass
Australian Commission on Safety and Quality in Healthcare (2010) National Consensus
Statement: Essential elements for recognising and responding to clinical deterioration
ACSQHC
Bleyer AJ, et al. Longitudinal analysis of one million vital signs in patients in an
academic medical center. Resuscitation (2011), doi:10.1016/j. Resuscitation, 2011.06.033
Clinical Excellence Commission, New South Wales Health (2010) Between the flags: Keeping
patient’s safe: guidelines and Implementation toolkit.
http://www.cec.health.nsw.gov.au/programs/between-the-flags Accessed 02/05/2011
Commission on Patient Safety and Quality Assurance (2008) Report of the Commission on
Patient Safety and Quality Assurance: Building a Culture of Patient Safety Department of
Health and Children
Connolly Hospital Blanchardstown (2011) Guideline for use of the Early Warning Score in
Connolly Hospital
Council of International Hospitals (2007) Tactics to Manage Deteriorating Patients: Literature
Review The Advisory Board Company Washington D.C.
CREST (2007) Guidelines on the Use of Physiological Early Warning Systems Clinical
Resource Efficiency Support Team – Northern Ireland http://crestni.org.uk/
Department of Health (2009) Competencies for recognising and Responding to Acutely Ill
Patients in Hospital NHS
http://www.dh.gov.uk/en/Publicationsandstatistics/Publicationspolicyand
Guidance/DH_096989
Dellinger,RP., Levy, MM., Carlet, JM., et al (2008) Surviving Sepsis Campaign: International
Guidelines for management of severe sepsis and septic shock Critical Care Medicine 36: 296
– 327 http://www.survivingsepsis.com/implement/resources/guidelines
Gao, H., McDonnell, A., Harrison, D.A. et al (2007) Systematic review and evaluation of
physiological track and trigger warning systems for identifying at risk patients on the ward.
Intensive Care Medicine. 33:667-79
Health Information and Quality Authority (2011) Report of the investigation into the quality
and safety of service and supporting arrangements provided by the Health Service Executive
at Mallow General Hospital http://www.hiqa.ie/
Health Information and Quality Authority (2010) Guidance on Development of Key
Performance Indicators and Minimum Data Sets to monitor Healthcare Quality
Health Service Executive (2011) Training Manual for the National Early Warning Score and
associated Education Programme
HSE Cavan & Monaghan, Louth/Meath Hospitals HSE DNE (2008) Guideline for Vital Signs
Assessment of Adults and the use of the Physiological Track and Trigger System ‘POTTS’
45
HSE Mid Western Regional Hospital (2010) Guideline for Vital Signs Assessment of Adults
and the use of the Simple Clinical Score (SCS) Assessment Tool and the HOTEL Monitoring Score
HSE South Tipperary General Hospital (2009) Modified Early Warning Scoring System:
Guidelines for staff
HSE Waterford Regional Hospital (2011) Guidelines for Healthcare staff in the use of a
Modified Early Warning Score (EWS)
Kellett J & Kim A. Validation of an abbreviated VitalpacTM Early Warning Score (ViEWS) in
75,419 consecutive admissions to a Canadian Regional Hospital. Resuscitation (2011),
doi:10.1016/j.resuscitation.2011.08.022
National Institute for Clinical Excellence (2007) Acutely ill patients in hospital: Recognition of
and response to acute illness in adults in hospital. NHS: National Institute of Clinical
Excellence. www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf
National Institute for Clinical Excellence (2010) Review of Clinical Guideline (CG50) Acutely Ill
patients in hospital http://www.nice.org.uk/nicemedia/live/11810/52356/52356.pdf
National Institute for Clinical Excellence/ Commission for Health Improvement (2002)
Principles for Best Practice in Clinical Audit Oxon: Radcliffe Medical Press
National Patient Safety Agency (2007) Recognising and responding appropriately to early
signs of deterioration in hospitalised patients NHS www.npsa.nhs.uk
New South Wales (NSW) Health (2010) Policy Directive: recognition and Management of a
Patient who is Clinically Deteriorating http://www.health.nsw.gov.au/policies/
New South Wales (NSW) Health (2010) Standard: Recognition and management of Patients
who are Clinically Deteriorating http://www.health.nsw.gov.au/policies/
Patient Safety First (2008) The ‘How to Guide’ for Reducing Harm from Deterioration NHS
www.patientsafetyfirst.nhs.uk
Perbedy MA, Cretikos M, Abella BS, De Vita M, Goldhill D, Kloeck W, Kronick SL, Morrison LJ,
Nadkarni V, Nichol G, Nolan J, Parr M, Tibballs J, van der Jagt EW, Young L (2007)
Recommended Guindelines for Monitoring, Reporting and Conducting Research on Medical
Emergency Team, Outreach and Rapid Response Systems: An Uystein-Style Scientific
Statement : A Scientific statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian Resuscitatio Council, European Resuscitation Council,
Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation
Council of Southern Africa, and the New Zealand Resuscitation Council); the American Heart
Association Emergency Cardiovascular Care Committee; the Council on
Cardiopulmonary,Perioperative, and Critical Care; and the Interdisciplinary Working Group on
Quality of Care and Outcomes Research Circulation 116: 2481-2500
Prytherch DR, Smith GB, Schmidt PE, Featherstone PI. ViEWS — Towards a
National early warning score for detecting adult inpatient deterioration. Resuscitation
2010;81:932–7.
Royal College of Physicians of Ireland, Irish Association of Directors of Nursing and Midwifery,
Therapy professions Committee, Quality and Clinical Care Directorate, Health Service
Executive (2010) Report of the National Acute Medicine Programme
http://www.hse.ie/eng/services/Publications/services/Hospitals/AMP.pdf
46
APPENDIX 1.Model of PATIENT OBSERVATION CHART(A3 format folded to A4 -
punched for insertion to patient’s record).
Table 1. Front Page
47
Table 2. Middle Pages (Patient Observation Chart)
48
Table 3. Back Page (Patient Observation Chart)
NOTE: The scoring parameters for the physiological signs identified in the nationally agreed Early Warning Score (ViEWS) in Table 1, must be strictly adhered to in
the event that an acute hospital decides to design other aspects of their own
observation chart.
49
APPENDIX 11: EWS PROTOCOL (Escalation Flow Chart)
50
Policy template Appendix III : Sample ISBAR Report
(Adapted from COMPASS© training programme)
51
Policy template APPENDIX IV: SIGNATURE SHEET
Please sign to indicate you have read and understand the HSE(2011) Guiding
Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration
PRINT NAME SIGNATURE Area of Work Date
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