Early Warning Score & Vital Sign Chart(s)

Proposed content for E-Learning

CCDHB Early Warning Score (EWS)

Welcome to the EWS and vital sign chart e-learning site. This resource provides an opportunity to learn about the use of the new adult EWS system, paediatric EWS (PEWS) and maternity (MEOWS).The online training will help you learn how to use the EWS and vital sign chart and operate the escalation pathway.Please note that the adult EWS is designed for use in adults aged 16 years and above. If you work in paediatrics please refer to the PEWS training, and for pregnancy & obstetrics please use the MEOWS training.

ADULT EWSBegin E-Learning

Links EWS matrix Wellington chart Kenepuru chart CNE’s teaching package EWS & vital sign policy

PEWSBegin E-Learning

MEOWSBegin E-Learning

Links PEWS matrices PEWS age-specific charts PEWS escalation pathway EWS & vital sign policy

Links MEOWS matrix MEOWS chart MEOWS escalation

pathway

Training Session: PAEDIATRIC

o Learning objectiveso PEWS parameterso Calculating a PEWS & recording vital signso Triggering a PEWS response & escalationo PEWS Quiz

Learning Objectives

After completion of this e-learning session you will be able to:1. Understand the benefits of the PEWS2. Describe the seven PEWS parameters3. Calculate an PEWS correctly4. Use the mandatory PEWS triggers to initiate a

mandated response5. Understand how the PEWS escalation pathway

works6. Know how the PEWS Modification Box is used

1. Benefits of EWS

Early Warning Scores (EWS) have been developed internationally, to help identify acutely ill and deteriorating patients in acute care hospitals

EWS focus on EARLY recognition of clinical signs of deterioration. EWS trigger a fast and efficient clinical response, which helps prevent deterioration to cardiac arrest. This EARLY approach to acute deterioration optimises patient outcomes.

Paediatric EWS (PEWS)

• In recent years Paediatric EWS have been developed internationally, with Toronto and Queensland publishing validated PEWS systems these have been implemented in a number of centres around NZ ( Starship, Kidz First and CHCH DHB1-4)

• The PEWS system (January 2014) is based on the Queensland CEWT system Adopted by CHCH DHB and used with kind permission. There is a move towards a standardised EWS across the sub-regional 3 DHBs (Hutt Valley, Wairarapa & CCDHB)

References

1. Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Archives of disease in childhood 2005;90(11):1148-52.

2. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. Journal of critical care 2006;21(3):271-8.

3. Haines C, Perrott M, Weir P. Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool. Intensive Crit Care Nurs 2006;22(2):73-81.

4. Monaghan A. Detecting and managing deterioration in children. Paediatric nursing 2005;17(1):32-5.

2. PEWS Parameters

There are 7 parameters that form the basis for the EWS:– Respiratory rate– Oxygen saturation– Supplemental oxygen– Respiratory distress– Systolic blood pressure– Heart rate– Level of consciousness

PEWS charts

There are 5 age-specific PEWS vital sign charts:– 0-3 months – 4-11months– 1-4 years– 5-11 years– 12 + years

For the purposes of this training, the 4-11month chart is used for all clinical examples

Link to chart

Link to chart

Link to chart

Link to chart

Link to chart

Respiratory Rate (4-11mth)

The PEWS triggers are sensitive to deterioration.

PET call criteria are triggered at <10 or >60 per minute

Measuring Respiratory Rate

• An elevated respiratory rate is one of the most sensitive indicators of acute illness in paediatric patients.

• To calculate an accurate respiratory rate, the patient’s breathing must be assessed for a full minute.

Respiratory Distress

The degree of effort (work of breathing) allows clinical assessment of the severity of respiratory disease.

Measuring Respiratory Distress

• Along with respiratory rate you are looking at the following:

Recession Inspiratory or expiratory noisesGruntingAccessory muscle useFlaring nostrilsGaspingEfficacy of breathing e.g. decreased air entry, chest

expansion

Supplemental Oxygen

The scoring system allows you to use either FiO₂ or O₂ L/min, as part of the EWS. Talk to CharlotteRegularly review your patient’s need for oxygen and if they don’t need it, remove it

All oxygen administration MUST be prescribed by a doctor, and regularly reviewed. Advanced Oxygen Therapy i.e BCPAP and Hi Flow Oxygen must be prescribed on the blue Advanced Oxygen prescription either prior to or at commencement of therapy.

Oxygen Saturation

For patients receiving supplemental O₂, SpO₂ targets must be documented in the patient’s clinical record, or medication chart

Measuring Oxygen Saturations

• Measurement of SpO₂ by pulse oximetry is now a standard practice in acute care settings.

• Decreased oxygen saturations can be an indicator of impaired pulmonary and cardiac function.

• When using a pulse oximeter, make sure that the nail/skin interface is clean from anything that might impair the trace e.g. nail polish

Systolic Blood Pressure

• Normal Blood Pressure varies with age.• Use of the correct cuff size is crucial if an accurate blood

pressure measurement is to be obtained. (width should cover 2/3 of the length of the upper arm, inside of cuff (bladder) no more than 1/3 of arms circumference)

Measuring Blood Pressure• Blood pressure is to be recorded as per existing standards; on

admission, preoperatively and on return to ward postoperatively.• In neonates and infants, blood pressure should be recorded if

renal disease or co-arctation of aorta are suspected or if there are signs of hypotension.

• Any child or adolescent should also have their blood pressure measured with symptoms of hypotension, hypertension, renal or cardiac disease, diabetes or adrenal disorder, head injury or trauma.

• Blood pressure should be recorded 4-8 hourly or more frequently if indicated. Use correct cuff size.

• Blood pressure must be recorded if the PEWS score is 3 or greater based on other parameters.

Heart Rate

Tachycardia is triggered at 160 per minute and bradycardia at 100. PET call criteria is a heart rate ≤60 per minute

Measuring Heart Rate• Heart rate is an important indicator of any acute condition• The normal heart rate varies with age and activity• Tachycardia may be due to a number of causes:

– Fever– Anaemia– Shock– Dysrhythmia– Sepsis– Metabolic disturbances especially due to dehydration– Pain/nausea/distress– Medications

• Bradycardia is often a sign of an impending cardiorespirtaory arrest. Other causes of bradycardiac may be an indicator of hypothermia, CNS depression, heart block or hypothyroidism.

• When assessing the heart rate it is best practice to manually feel for the pulse, rather than rely on pulse oximetry. Palpation will provide important clinical information e.g. skin temperature, regularity and strength of pulse

Level of Consciousness

A decreased level of consciousness is an indicator of CNS depression and narcosis

The AVPU assessment is a quick and accurate tool to measure and record a patient’s level of consciousness:

A – alert or awakeV – responds to voiceP – responds to pain stimulusU - unresponsive

3. Using PEWS

• The minimum frequency for taking a full set of vital signs & calculating the Early Warning Score is every 4 hours (Adult & paediatric vital sign measurement, EWS and escalation policy. Document ID 1.101901.

• The frequency for taking vital signs may be increased or decreased, according to the clinical need of each patient.

• Each EWS parameter is weighted, so that the greater the deviation from normal, the higher the EWS score. The weighted scores range from 0 (normal) to 3 (grossly abnormal).

• The individual parameter scores are then added together to derive an aggregated EWS. If significant, a clinical response is triggered

The vital sign charts have colour-coding to help identify each EWS zone:

o White = normalo Yellow = potential to deteriorateo Orange = indicates acute illness or unstable chronic diseaseo Red = likely to deteriorate rapidly o Blue = immediately life threatening critical illness

The PEWS system also allows for single parameter scoring e.g. if any vital sign falls in a coloured zone, the associated action is triggered.

PEWS Process

1. Measure & document a

full set of vital signs

2. Calculate & document the

PEWS

3. Use the PEWS to

identify the appropriate

level of escalation

4. Consider most

appropriate clinical setting

for ongoing care

4. PEWS Matrix (4-11mth)

25

SCORE PET 3 2 1 0 1 2 3 PET

ZONE BLUE RED ORANGE YELLOW WHITE YELLOW ORANGE RED BLUE

Resp Rate <10 10-15 15-20 20-45 45-50 50-55 55-60 >60

SpO₂ ≤85 85-88 89-92 93-100

Supplemental O₂ 0-2L21-30%

2-10L30-39%

11-14L40-50%

≥15 L>50%

Respiratory Distress nil mild moderate severe

Sys BP <50 50-55 55-65 65-75 75-120 >120

Heart Rate <60 60-80 80-90 90-100 100-160 160-170 170-190 >190

Level of Consciousness Alert Voice Pain Unresponsive

or fitting

Wellington Hospital’s vital sign chart

5. Escalation Pathway

The PEWS escalation pathway is MANDATORY and has been endorsed for use by clinical directors and managers. Any deviations away from this pathway must be documented in the patient’s clinical record

PEWS 1-3 (4-11mth)

PEWS 4-5 (4-11mth)

PEWS 6-7 (4-11mth)

PEWS 8+ (4-11mth)

The colour associated with paediatric emergency team calls (PET) is BLUE

• The PEWS system does not replace sound clinical judgment

• If you are seriously concerned about any patient, regardless of vital signs/PEWS, call ‘777 PET’

• Alternatively, if there is no timely response to your request for review, escalate to the next coloured zone.

6. Modification to PEWS Triggers

• There are cases when clinically stable patients may have abnormal vital signs. In order to accommodate this and prevent alarm-fatigue from over-triggering patient reviews, the PEWS can be modified

• Any modification to the PEWS must be made by a Consultant or Registrar and be regularly reviewed by the primary team

• Modification to PEWS must never be used to normalise abnormal vital signs in clinically unstable patients, or deter ward staff from accessing the help they need e.g. preventing 777 calls from being made

CCDHB PEWS Modification Box

Paediatric EWS Quiz

True or False?

• PEWS focus on early recognition of clinical signs and help identify deteriorating patients

• PEWS have been shown to decrease numbers of in-hospital cardiac arrest & respiratory arrest

• CCDHB’s PEWS is based on a validated PEWS system which has been demonstrated to be superior to all others at predicting mortality.

• What are the 7 PEWS parameters?– Respiratory distress – Heart rate – Level of consciousness – Urine output – Oxygen saturation – Systolic blood pressure – Supplemental oxygen – Diastolic blood pressure – Respiratory rate

Which of the vital signs is considered the most sensitive indicator of acute illness?– Temperature – Heart rate – Respiratory rate

At CCDHB, what is the minimum frequency of vital signs to be taken on every patient?– Daily – Once per shift – 6 hourly – 4 hourly

Use the 4-11month PEWS Matrix (insert link to PEWS matrix) to calculate the PEWS:– Respiratory Rate 58 – Oxygen Saturation 91% – Supplemental Oxygen 11L – Respiratory Distress severe – Systolic BP 105 – Heart Rate 132 – Conscious level Alert

– Respiratory Rate 58 – Oxygen Saturation 91% – Supplemental Oxygen 11L – Respiratory Distress Severe

– Systolic BP 105 – Heart Rate 132 – Conscious level Alert

The correct PEWS is 9

EscalationResponse

Use the 4-11month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS:– Respiratory Rate 51 – Oxygen Saturation 97% – Supplemental Oxygen FiO2 33% – Respiratory Distress mild – Temperature 37.5 – Systolic BP 110/82 – Heart Rate 145 – Conscious level Alert

– Respiratory Rate 51 – Oxygen Saturation 97% – Supplemental Oxygen FiO2 33% – Respiratory distress mild – Temperature 37.5 – Systolic BP 110/82 – Heart Rate 145 – Conscious level Alert

The correct PEWS is 4

EscalationResponse

Use the 4-11 month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS:– Respiratory Rate 51 – Oxygen Saturation 92% – Supplemental Oxygen 3L – Respiratory distress mild – Temperature 38.2 – Systolic BP 115/82 – Heart Rate 171 – Conscious level Voice

– Respiratory Rate 51 – Oxygen Saturation 92% – Supplemental Oxygen 3L – Respiratory distress mild – Temperature 38.2

– Systolic BP 115/82 – Heart Rate 171 – Conscious level Voice

The correct PEWS is 9

EscalationResponse

Place the PEWS processes in the correct order

Measure & document a

full set of vital signs

Calculate & document the

PEWS

Use the PEWS to identify the

appropriate level of

escalation

Consider most appropriate

clinical setting for ongoing

care

True or False?

The PEWS chart is used throughout adult wards at Kenepuru and Wellington campuses There are 5 age-specific PEWS charts

The colour-codes used to help identify each PEWS zone are: yellow, orange, pink and blue

True or False?

The PEWS replaces sound clinical judgment

The PEWS modification box must only be filled in by a Consultant or a Registrar

Pink is the colour associated with triggering PET