Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1 Early Warning Score (EWS) Management Protocol
1.1
Education of staff ............................................................................................... 3
1.2
Clinical staff responsibilities .............................................................................. 3
1.3
Communication/handover requirements ............................................................ 5
1.4
Evaluation ........................................................................................................... 5
1.5
Appendix One: Adult Early Warning Score (EWS) Management Protocol ...... 6
1.6
Appendix Two: Modified Early Obstetric Warning score (MEOWS)
Management Protocol......................................................................................... 7
1.7
Appendix Three: Paediatric Early Warning Score (PEWS) Management
Protocol .............................................................................................................. 8
Policy Statement
EWS tools assist with the recognition and appropriate management of
clinically deteriorating patients and the patient at risk of clinical
deterioration and is complimentary to skilled clinical assessment and
decision making.
Purpose
An Early Warning Score must be used for all patients within a hospital
setting when recording observations/vital signs, to aide:
Early detection of detrimental changes
Safe, timely, effective management of care in response to a
patients deteriorating condition.
The EWS is required to be communicated between staff when
transferring patients between areas and with requests for clinical
assistance.
Variations
Maternity patients use the Modified Early Obstetric Warning Score
(MEOWS).
Paediatric patients up to 15 years of age, use the age appropriate
Paediatric EWS (PEWS).
The Neonatal ICU is exempt from using PEWS.
For the purposes of this policy when the term EWS is used, this
encompasses the EWS, MEOWS and PEWS.
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 1 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
Audience/Scope
CDHB Medical, Nursing and Midwifery staff
Associated Documents
CDHB EWS Management Protocol Booklet
CDHB EWS Education packages
CDHB EWS Audit tool
CDHB EWS Lanyard Cards (in development)
CDHB Adult Observation Chart C280010
CDHB MEOWS chart (in development)
CDHB Paediatric Observation Chart (0 3 months) C280011A
CDHB Paediatric Observation Chart (12 months) C280011B
CDHB Paediatric Observation Chart (1-4 years) C280011C
CDHB Paediatric Observation Chart (5-11 years) C280011D
CDHB Paediatric Observation Chart (11-15 years) C280011E
CDHB PEWS Lanyard Cards (in development)
CDHB Neuroscience Observation Chart C280014
CDHB Neurology Observation Chart C180002
CDHB ISBAR Communication Policy Vol 11
CDHB ISBAR CDROM
CDHB ISBAR Lanyard Cards ref 2299
CDHB Transfer of Patients between Hospitals Vol 11
CDHB Maternity Acute Observation Chart C280090
CDHB Adult Cardiology Observation Chart C280094
CDHB Paediatric HDU Observation Chart (0 3 months) C280016A
CDHB Paediatric HDU Observation Chart (12 months) C280016B
CDHB Paediatric HDU Observation Chart (1-4 years) C280016C
CDHB Paediatric HDU Observation Chart (5-11 years) C280016D
CDHB Paediatric Observation Chart (11-15 years) C280016E
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 2 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1.1
Education of staff
All staff within the scope of this policy must receive clinical training on
the EWS Management Protocol.
Staff must be aware of their responsibilities within the protocol as part
of the division and ward/unit orientation.
1.2
Clinical staff responsibilities
All patients must have a documented plan for the monitoring of
observations that is clinically appropriate for the patient.
1.2.1 Nursing Observation Responsibilities
For an adult patient, the following observations/symptoms must be
recorded to obtain an accurate EWS:
Respiratory rate calculated over 1 minute
Heart rate for at least minute
Blood pressure
Conscious level using the AVPU
Temperature (by a consistent method)
Urine output
For a maternity patient, the following observations/symptoms must be
recorded to obtain an accurate MEOWS:
Respiratory rate calculated over 1 minute
Heart rate for at least minute
Blood pressure
Conscious level using the AVPU
Temperature (by a consistent method)
Urine output
Lochia (post natal)
Proteinura (ante and post natal)
Reflexes (ante and post natal)
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 3 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
For a Paediatric patient the following observations/symptoms must be
completed on admission to obtain accurate PEWS. Subsequent
observation requirements are determined by the PEWS management
plan and/or the medical team.
Respiratory rate calculated over 1 minute
Respiratory distress score
Pulse oximetry
Heart rate for at least minute
Blood pressure
Conscious level (using the AVPU)
Capillary refill time
Note whilst temperature is not included in the PEWS, a baseline
temperature recording is taken on admission and four hourly thereafter
for an inpatient.
1.2.2 Protocol Management and Documentation Responsibilities
Nursing staff must calculate the EWS from the observations/symptoms
and document the score on the appropriate observation chart or in the
clinical notes.
All clinical staff must follow the appropriate EWS management
protocol according to the EWS calculation.
All clinical staff will document any variances from the EWS in the
clinical notes and update care plan/pathway.
If a EWS score is explainable and acceptable for a patient based on
clinical judgement, the reason(s), acceptable observation parameters
and an alternative management plan must be clearly documented by
medical staff in the patients clinical record.
Medical staff must document the following within the clinical notes for
each patient review:
The EWS
Reason for review e.g. ward round, review requested, etc
Assessment and management plan
If an additional review is requested indicate the time frame for this
review to prevent further patient clinical deterioration.
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 4 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1.3
Communication/handover requirements
Any pathway communication/handover with other staff i.e. Medical
Staff or Clinical Team Coordinators, is provided using the ISBAR
communication method stating the:
Patients condition/diagnosis
Patients EWS
The components of observations that drove the score
What actions have already been taken
Clarification of actions to take following the communication i.e.
repeat EWS in set timeframe and contact medical staff again if
required.
1.4
Evaluation
Regular compliance audits of the use of the EWS Management protocol
will be conducted in areas using the CDHB EWS/MEOWS/PEWS
Audit tool.
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 5 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1.5
Appendix One: Adult Early Warning Score (EWS) Management
Protocol
From the back of the Adult Observation Chart C280001
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 6 of 8
Issue Date: June 2013
Review Date: June2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1.6
Appendix Two: Modified Early Obstetric Warning score (MEOWS) Management Protocol
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 7 of 8
Issue Date: June 2013
Review Date: June 2014
Volume 11: Clinical
Canterbury DHB
Early Warning Score (EWS) Management Protocol
1.7
Appendix Three: Paediatric Early Warning Score (PEWS) Management
Protocol
Policy Owner
Department of Nursing, Christchurch Hospital
Date of Authorisation
June 2013
Authorised by Chief Medical Officer and Executive Nursing Director
Ref: 0928
Page 8 of 8
Issue Date: June 2013
Review Date : June 2014
