Introduction:
Early warning scores (EWS) are used in hospitals to identify the clinical signs of deterioration and provide them with immediate medical attention and intensive medical care. Early medical intervention is done by activating a rapid response team, nursing attention, information to the provider, and activating the medical emergency team. These cumulative tools carry a single composite numeric for identifying patients who can develop a serious clinical event. Physiologic parameters include heart rate, blood pressure, oxygen saturation, respiratory rate, consciousness, and urine output. These EWS scores should be communicated between staff when patients are transferred to a different place for clinical assistance.
What Are the Types of Early Warning Scores?
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NZEWS (New Zealand Early Warning Score): It is a nationally standardized tool for non-maternal adults in New Zealand.
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MEWS (Maternity Early Warning Score): The MEWS tool is used for pregnant women and women post gestation up to six weeks after delivery.
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NEWS (Newborn Early Warning Score): This tool is used for neonates and incorporated into the NOC (newborn observation chart).
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PEWS (Pediatric Early Warning Score): This tool is used in pediatric patients up to 15 years of age.
National Early Warning Score:
Refer to this for color coding -
Red Score: It refers to an extreme variation in a single physiological parameter.
What Are the Parameters Used for Interpreting Early Warning Scores?
1. Adult Patients:
The following parameters are used in interpreting NZEWS:
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Oxygen saturation percentage (SpO2).
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The respiratory rate for more than a minute.
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Oxygen therapy presence.
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Heart rate monitoring for at least 30 seconds.
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Blood pressure using appropriate cuffs.
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Level of consciousness through AVPU (alert, voice, pain, unresponsive).
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The temperature was recorded using a consistent site and method.
2. Pregnant Women:
The following parameters are used in interpreting MEWS:
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Oxygen saturation percentage (SpO2).
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The respiratory rate for more than a minute.
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Supplemental oxygen administration.
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Heart rate monitoring for at least 30 seconds.
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Blood pressure recordings.
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Level of consciousness.
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The temperature was recorded on a consistent site and method.
3. Pediatric Patients:
The following parameters are used in interpreting PEWS:
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Oxygen saturation percentage (SpO2).
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Respiratory distress score.
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The respiratory rate for more than a minute.
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Heart rate monitoring for at least 30 seconds.
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Blood pressure.
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Capillary refill time.
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Level of consciousness through AVPU (alert, voice, pain, unresponsive).
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Temperature is not included, but a baseline temperature is recorded after admission and after four hours in an inpatient if the reading is within normal limits.
4. Neonates:
In neonates, the immediate postnatal period is from one to two hours post-birth, and after 24 hours, the following parameters are recorded after observation:
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The respiratory rate for more than a minute.
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Breathing.
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Temperature.
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Color (including jaundice).
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Behavior and feeding.
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Heart rate monitoring for over a minute.
What Are the Strengths and Limitations of Early Warning Score Systems?
A major strength of the early warning score system is its simplicity and ability to calculate scores using routine bedside observations. They will provide a standardized communication framework, allowing all team members to coordinate rapidly and manage the interventions. They will also allow for faster and more accurate recording of clinical parameters.
The limitations of early warning scores are challenges with implementation, such as non-adherence to the tools and framework, the potential for increased use of healthcare resources, and the validity of measures used.
What Is the Significance of the Physiological Parameters in EWS?
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Respiratory Rate: If the respiratory rate is changed, it can mean serious illnesses. An increased rate can indicate an acute illness, generalized pain, sepsis, CNS (central nervous system) disturbance, and metabolic acidosis. A decreased respiratory rate can indicate CNS depression and narcosis.
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Oxygen Saturation: Oxygen saturation is measured by pulse oximetry and is considered an important tool for assessing pulmonary and cardiac function.
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Temperature: Extremes of temperature like pyrexia and hypothermia can signify acute illness or a physiological disturbance.
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Blood Pressure: Systolic blood pressure alteration is considered important. Elevated systolic blood pressure (hypertension) is considered a risk factor for cardiovascular disease. Reduced blood pressure (hypotension) can be used to assess acute illness severity, sepsis, CNS depression, cardiac failure or cardiac rhythm disturbance, and hypoadrenalism.
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Pulse Rate: Heart rate is an important indicator of a patient's condition. Tachycardia can indicate circulatory compromise due to cardiac failure, pyrexia, sepsis, or arrhythmia. Bradycardia indicates hypothermia, CNS depression, hypothyroidism, and heart block.
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Conscious Level: Consciousness is assessed as altered consciousness that can lead to potentially threatening conditions.
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Alert: A fully awake patient with motor function and will respond to voice.
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Voice: The patient will respond through voice with a little grunt, moan, or slight limb movement when asked a question.
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Pain: Patients will respond to pain stimuli but no voice response or motor function.
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Unresponsive: This state is called unconscious, and the patient does not give any kind of response.
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New Set of Confusion: The patient may be confused but alert.
What Are the Responsibilities of Clinical Staff?
A thorough documentation of the plan of care, frequency of monitoring vital signs, and limitations in patient care should be done for each patient.
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Recognition Activation: The patient should be given privacy, and informed consent is required. Vital signs should be measured using appropriate techniques.
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Response Escalation: Patients' responses should be recorded in the clinical notes, and any changes should be immediately notified. It should be escalated if there is a need for a higher level of care needs or treatment limitations.
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Communication: Handover or transfer of care requirements with the other staff should be done by communicating the following:
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Patient's condition.
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Diagnosis of the patient's condition.
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Parameters that derived the score.
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Actions done previously.
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The plan of action is to be repeated while transferring care.
What Are the Potential Benefits of a Standardized EWS?
There will be a single EWS system for early detection of an unwell patient having acute symptoms by assessing specific physiological parameters in a standard way. A standardized score for determining the severity of illness will help in clinical decision-making and provide an appropriate clinical response. Standardizing the EWS will help provide standard training and education for clinical staff in detecting and managing patients in their early clinical careers. Hospital transfer can be done hassle-free if there is a universal score.
Conclusion:
An early warning score is important in clinical setup for identifying a patient that needs immediate medical attention and a swift treatment plan. By doing so, the need for admitting patients to intensive care units has also been reduced. It has also been useful in unresponsive patients and neonates. This standardized tool has made it trouble-free to transfer patients from one hospital to another for clinical needs.
