The document discusses the Early Warning Score (EWS) system, which is a simple scoring method used to rapidly identify clinically deteriorating patients based on 5 physiological parameters. Studies have shown that implementing an EWS protocol can effectively reduce mortality and morbidity for deteriorating patients as well as prevent ICU admissions. The EWS allows for early detection of patients who need urgent medical review and intervention to avoid further physiological deterioration.

1. Dr Ahmed Hankir Medical House Officer, MBChB, The Royal Oldham
Hospital, Pennine Acute Trust, Greater Manchester, England
Mr Ahmed Soussi, Consultant General Surgeon MBChB FRCS (Glas)

2.  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.

3.  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.

4.  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)

5.  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.

6.  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

7.  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 .

8. 
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.

9. 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 .

10.  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.

11.  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.

12.  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!!)