The early warning score (ews)

Dr Ahmed Hankir Medical House Officer, MBChB, The Royal Oldham Hospital, Pennine Acute Trust, Greater Manchester,

EnglandMr Ahmed Soussi, Consultant General Surgeon MBChB FRCS

(Glas)

In the United Kingdom, the Early Warning Score (EWS) is now commonly used for the assessment of unwell patients.

The EWS is a simple scoring system that utilizes physiological parameters.

The EWS is reproducible(1) and can be utilized to rapidly identify patients who are clinically deteriorating and who need urgent intervention.

The EWS can be utilized to monitor medical, pre and post operative patients and A&E patients.

The EWS is a calculation of 5 physiological parameters: mental response (AVPU system), HR, SBP, RR and Temp.

The concept is that small changes in these five parameters will be detected earlier using EWS than waiting for obvious changes in individual parameters such as a marked drop in SBP which is often heralded by a terminal event.

RR is the most important parameter but the least recorded. RR is thought to be the most sensitive indicator of a patient’s physiological well-being (2,3,4)

This is logical since RR reflects not only respiratory function as in hypoxia or hyercapnia, but cardiovascular status as in pulmonary oedema and metabolic imbalance i.e. DKA.

The EWS can be calculated as part of a routine recording of a patient’s vital signs and when the nursing staff are concerned that a patient may be deteriorating.

It helps to monitor a patient’s clinical progress and gives early warning of any deterioration.

Repeated measurements can track the patient’s improvement or deterioration with simple interventions like oxygen or fluid therapy.

Serial EWS readings are more informative than isolated readings as they give a picture of the patient’s clinical progress over time.

The EWS allows deteriorating patients to be identified prior to physiological deterioration becoming too profound.

An EWS score of 3 or more should stimulate a rapid assessment of the patient by a ward doctor or, if available, the ICU team. If deteriorating patients are identified early enough, simple interventions may prevent further deterioration and imminent collapse.

EVIDENCE: THE APPLICATION OF THE EWS PROTOCOL HAS BEEN SHOWN TO EFFECTIVELY REDUCE THE MORTALITY AND MORBIDITY OF DETERIORATING PATIENTS AS WELL AS PREVENTING ICU ADMISSIONS (5,6,7,8,9,10)

Studies have indicated that an EWS of 3 or more requires urgent attention (4,6)

In many UK hospitals a score of 3 triggers an immediate review by a ward doctor. If no improvement is seen the most senior ward nurse can then escalate to a senior doctor.

Some centers have taken it even further and an EWS of 3 or more results in an immediate call directly to the ICU registrar for a ward review. Other centers have a higher treshold for ICU referral and use a score of 4 or even 5 as a trigger for calling out.

The EWS is calculated from five simple physiological parameters

It is capable of identifying patients who may have an adverse outcome and as such should receive urgent medical assessment and intervention.

Scores of 3 or more on the EWS is associated with an increased risk of death (OR 5.4, 95% CI 2.8-10.7) and ICU admission (OR 10.9, 95% CI 2.2-55.6)

The application of the EWS has been shown to effectively reduce the mortality and morbidity of deteriorating patients as well as preventing ICU admissions

A 60 year old gentleman a/w SOB. Not c/o CP. H/O ACS and awaiting CABG. PMH of asthma. On admission, he was alert, RR=30, HR=130, SBP 108. EWS=5. Assessed by emergency doctors. Neb Salbutamol and oxygen therapy given. He appeared to be improving clinically. His RR dropped to 24, HR was 124, temp remained the same but his SBP had dropped to 95. Therefore his clinical appearance belied his physiological status with an EWS of 6 suggesting that he was still deteriorating. Intensive care team contacted and patient admitted to HDU for observation and treatment. He was found to be septic from an LRTI. This case illustrates that subjective judgments made on clinical appearance alone can be misleading. More accurate judgments are made on the objective basis of calculating an EWS using physiological parameters .

A 72 year old gentleman arrived in recovery post Whipple procedure for resection of his pancreas for pancreatic tumour. He had lost 3 liters of blood intra operatively and was receiving blood transfusions. Initially in recovery he was alert, HR 70, RR 15, SBP 110. his EWS was 1. Over the next three hours he became tachycardic and hypotensive. He remained alert, HR 105, RR 20, SBP 95. His temp was not recorded. His EWS has therefore risen to 4. Despite this, a doctor did not review him and he was sent back to the ward. By midnight he was drowsy, had an RR of 30, temp of 38.5 HR 120 SBP of 90. His EWS became 11. He was finally reviewed, actively resuscitated and taken back to theatre for an exploratory laparotomy. Two liters of blood and a clot were found in his abdomen from a bleeding artery. He was in hypovolaemic shock. He was sent intubated to the ICU and remained there overnight. If the EWS protocol had been followed this patient would never have left recovery. All the signs were there from a very early stage that he was deteriorating. Early intervention would have averted the development of a hypovolaemic shock and possibly an ICU admission.

1 Stubbe CP., Kruger M., Rutherford P., Gemmell L. Validation of a modified Early Warning Score in medical

admissions. Quarterly Journal of Medicine 2001;94:521-526 2 Fieselmann J et al. Respiratory rate predicts cardiopulmonary arrest for internal medicine patients. The Journal of

General Internal Medicine. 1993;8:354-360. 3 Kenwood G, Hodgetts T, Castle N. Time to put the R back in TPR. Nursing Times. 2001;97:32-33. 4 Stubbe CP., Davies RG., Williams E., Rutherford P., Gemmell L. Effects of introducing the modified Early Warning

Score on clinical outcomes, cardio-pulmonary arrests and intensive car utilisation on acute medical admissions. Anaesthesia, 2003;58:775-803.

5 Allen A, McQuillan P, Taylor B, Neilson M, Collins C, Short A, Morgan G, Smith G. Who sees the critically ill patient before ICU admission. Clinical Intensive Care, 1994;5:152.

6 Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A. The Medical Emergency team; a new strategy to identify and intervene in high-risk patients. Clinical Intensive Care 1995;6:269-72.

7 Goldhill D, White S, Sumner A. Physiological values and procedures in the 24 hours before ICU admission from the ward. Anaesthesia. 1999;54:853-860.

8 McGoin H, Adam S, Singer M. The quality of pre-ICU care influences outcome of patients admitted from the ward. Clinical Intensive Care; 1997;8:104.

9 McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nieslon M, Barrett M, Smith G. Confidential enquiry into quality of care before admission to intensive care. British Medical Journal 1997;316:1853-1857.

10 Buist D, Moore G, Bernard S, Waxman B, Anderson N, Nguyen T. Effects of a medical emergency team on the reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary review. British

Medical Journal 2002;324:387-90.

Intensive Crit Care Nurs. 1994 Jun;10(2):115-20 At Liverpool Hospital in 1989, mortality from cardiopulmonary arrest was 71% in

the general wards, and 64% in the Emergency department. In an attempt to identify and treat seriously ill patients before they progressed to cardiac arrest, a medical emergency team (MET) was established. The MET replaced the existing cardiac arrest team and comprised a nurse from the intensive care unit (ICU), a resuscitation registrar (an anaesthetics trainee), a medical registrar and a senior registrar from the ICU. The resuscitation registrar was the team leader. The calling criteria for the MET were based on predetermined physiological variables, abnormal laboratory results, and specific conditions or if nursing or medical staff were concerned by the patient's condition. A study was conducted 2 years following implementation of the MET system, to determine registered nurses' (RNs) opinions, knowledge and use of the system. A questionnaire distributed to 141 nurses rostered on the chosen study date revealed a positive attitude the MET, although there was a low awareness regarding the availability of the MET information booklet. 53% of nurses had called the MET in the last 3 months; all would call the team again in the same circumstances. The correct response in three of four hypothetical situations presented was to call the MET. The number of correct responses varied between scenarios from 17-73%. Hypotension did not appear to alert nurses to summon emergency assistance. Some nurses, despite the presence of severe deterioration and patient distress, called the resident rather than the MET.

OBJECTIVES: (i) To determine the incidence of unexpected deaths occurring on general wards, and whether any were

potentially avoidable; (ii) to assess whether the quality of care on general wards prior to admission to intensive care affected subsequent outcome.

DESIGN: Six-month audit in teaching hospital. Review of medical, nursing and physiotherapy notes, bedside charts

and laboratory data in ward patients either dying unexpectedly (i.e. not having a prior 'do not resuscitate' order) or requiring intensive care unit (ICU) admission. Panel assessment of quality of ward care prior to unexpected ward death or ICU admission.

SUBJECTS: Adult general ward patients admitted to ICU or dying unexpectedly. OUTCOME MEASURES: ICU and hospital mortality. RESULTS: (i) In the six-month study period, 317 of the 477 hospital deaths occurred on the general wards, of which 20

(6%) followed failed attempts at resuscitation. Thirteen of these unexpected deaths were considered potentially avoidable: gradual deterioration was observed in physiological and/or biochemical variables, but appropriate action was not taken; (ii) in the same period, 86 hospital inpatients were admitted on 98 occasions to the ICU, 31 of whom received suboptimal care pre-ICU admission due either to non-recognition of (the severity of) the problem or to inappropriate treatment. Both ICU (52% vs 35%) and hospital (65% vs 42%) mortality was significantly higher in these patients compared to well managed patients (p < 0.0001).

CONCLUSIONS: Patients with obvious clinical indicators of acute deterioration can be overlooked or poorly managed on the

ward. This may lead to potentially avoidable unexpected deaths or to a poorer eventual outcome following ICU admission. Early recognition and correction of abnormalities may result in outcome benefit, but this requires further investigation.

To continue with how things are or to change to the EWS? Does the former or the latter reflect the best medical

practice? Proposition: To introduce the EWS to Labib Medical Center Strengths of the EWS have been enumerated and

evidence has been presented. EWS used as a standardized tool across centers in the UK.

Training of staff required Cost-effectiveness a potential consideration Qualitative research can elicit views of service providers.

Results can be presented in an international conference and published in a peer-reviewed journal (refer to abstract 1 in handout -remember the dictum publish or perish!!)