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Early warning scores: effective use


A trust has lowered its mortality ratio by improving compliance in EWS monitoring


In June 2008, North Tees and Hartlepool Trust signed up to Patient Safety First. Our objectives were to put patients first and to develop a culture of patient safety. We implemented the intervention discussed here with the aim of preventing harm and reducing in-hospital cardiac arrest and mortality through earlier recognition and treatment of deteriorating patients. There is evidence that acute illness is exacerbated by “failure to act” on recognised changes (Hillman et al, 2001). Analysis of serious patient safety incidents revealed that 11% of deaths were related to “deterioration not recognised or not acted upon” (NPSA, 2007). Points where the process can fail include: not taking observations, not recognising early signs of deterioration, not communicating observations causing concern and not responding to concerns appropriately (NPSA, 2007). We focused on improving all these areas.

Citation: Smith S (2011) Early warning scores: effective use. Nursing Times; 107: 3, early on-line publication.

Author: Sue Smith is director of nursing and patient safety, North Tees and Hartlepool NHS Trust.


Early warning scores (EWS) rate individual patients’ risk of serious deterioration. The system is derived from four physiological readings and observing patients’ levels of consciousness.  Although the trust introduced EWS in 2007, there had been no formal audit or associated training.

In November 2008, we started to use the Global Trigger Tool (GTT) (Griffin and Resar, 2009) to review the clinical records of recently discharged patients on a weekly basis. This showed that nursing and medical staff could improve management of EWS.

In February 2009, we carried out a baseline audit to aid our understanding of areas of best practice and those requiring improvement. Then, we took steps to increase staff knowledge, skills and communication related to EWS.

Early warning scores and subsequent action taken by nursing and medical staff are monitored through a monthly quality review panel consisting of the director of nursing and the senior nursing team. Weekly reviews of EWS were undertaken in specific areas, supported by training from critical care educators. The trust has also introduced clear escalation processes that have further supported improvement, and we conduct a quarterly trust-wide audit to show the impact of this work.

Nurses’ role

Nurses have developed innovative solutions to improve the management of deteriorating patients. For instance, nurses on medical and orthopaedic wards stop the clock every four hours to conduct observations. EWSs then go on a ward board and medical colleagues join the nurses to do a board round. Decisions are made every four hours, which helps clinical teams act promptly and appropriately.

To monitor patient perceptions of care, we ask them to rate the support they have received. This means they are assessing us based on their confidence in our nurses.


The May 2009 audit showed significant improvements in all criteria assessed (Table 1). This reflects the commitment of our medical and nursing staff to work together to improve every aspect of patient care and safety.

The work has continued to develop. Our mortality ratio is now the lowest in the North East and a positive outlier nationally, whereas it was the highest two years ago and a negative outlier nationally; management of the deteriorating patient has significantly contributed to this improvement. We now do a full root-cause analysis of every cardiac arrest which includes looking at what happened in the 48 hours prior to the arrest. Over the last 6 months, only one patient who had a cardiac arrest experienced a deterioration of their observations in the time leading up to the arrest.


Readers' comments (6)

  • early warning scores are a part of any shift on our ward at a large teaching hospital and it is our job to make sure that the observations taken by our NA's are reported if there is a discrepency especially if they are scoring. There are a few however that do not always report to the registered nurse and when a problem arises can make a person feel really silly but as this is our registration. I have started to make a point to check them all as soon as they have been completed for the patients safety and the protection of my registration, as they are not their for the unqualified staff to interprate.If there is a problem i ask them to repeat them in an hour, and then if no improvement then report to the doctor. The best way to take observations is manually with a sphyg and manual pulse as a lot of nurses are losing the skill to do these basic tasks due to the digital age of computers and machiines.

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  • I agree with 'Anonymous/4 Feb 2011 1:24 pm that the manual taking of vital signs is important. I'm an Emergency Nurse Practitioner in the independent sector but quite often I'll do screening - pre-employment, well-person, etc - and a while ago I decided to some electronic blood pressure machines give inaccurate readings. For 50 screenings, I took the blood pressure manually and using a monitor and on most occasions (93%) the machine gave a false high reading. Granted, my sample size was small but it was enough for me to continue using only manual sphygs. Furthermore, as a flight nurse on F/W aircraft, although it's sometimes difficult to hear anything through a stethoscope due to ambient noise (especially so in light a/c), I still prefer manual methods because machines are so easily fooled - either by vibration of the a/c, turbulence or G forces.

    The same holds true for using a pulse oximeter as the only method of taking a pulse. The reading will be inaccurate in cases of irregular pulse plus it doesn't differentiate between haemoglobin and carboxyhaemoglobin. It will also be inaccurate of the patient is anaemic.

    Manual taking of vital signs should be the gold standard. Using monitors should be a last resort unless you can be absolutely sure there are no factors that may invluence the readings.

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  • 'The system is derived from four physiological readings and observing patients’ levels of consciousness.'

    Great - the RCP/RCN has just recommended a standardised NEWS chart using 6 indicators for scoring, designed to be as idiot-proof as possible, and a system using 5 indicators is being discussed above ! The RCP explained the advantages of STANDARDISED and used by everyone, quite clearly.

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  • I have to say that the use of NEWS or as we call it MEWS in our trust has really helped staff in identifying patients that are acutely ill. I don't see any difference in the usage of manual or electronic devices in taking the patient's observations because at the end of the day - we need to use our own clinical judgement or should I say our gut feeling to determine if the patient is acutely unwell or not. any abnormality in the patient's observations should send out an alert that as a staff who looks after that patient, you need to completely asses and observe him; the decision is yours whether that patient needs an hourly observation or not or whether the patient needs to be seen by the medical doctor right away.
    this is where appropriate and thorough training is needed to empower every staff in developing their assessment skills to provide a Gold standard care.

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  • A modified early warning system has been in place in the north west/merseyside region since 2003. It is an essential tool which prevents the incidences of cardiac arrests and other emergencies. early detection of emergencies improves survival rates. It is good that a national standard is being considered and recognised.

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  • i too agree

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