Early Warning Scoring System

& RRT
Presenter: Zharlene Padilla, BSN, RN
Unit 9 Staff Nurse
Objective:
At the end of this lecture, learners will be able to:
· Define Early warning system
· Discuss the EWSS guidelines according to policy
· Demonstrate accurate patient assessment and correct scoring
· Discuss appropriate action based on EWSS
· Discuss Indicators that requires immediate referral to physician
· Demonstrate activation of RRT (virtual)
· Discuss effective communication using SBAR during RRT
EARLY WARNING SYSTEMS
· rely on observations of the physiological status of the patient, reflecting a clinical evaluation of oxygen delivery and organ
perfusion.
· predict which patients are in need of and, allow preventive management, and determine who might need a step up to higher levels
of care. Rather than wait for an obvious change in an individual variable the trend over time can be objectively observed.

Guidelines:
· Respiratory rate is to be the most sensitive indicator of a patient’s physiological wellbeing.
· The modified early warning scores system is an updated version of the early warning scores system, adding two parameters—a
patient’s urine output and deviations from their normal blood pressure.
· If the total score exceeds a predefined cut-off this triggers immediate actions (including calls for ICU specialist).
· Identification of the sick patient is not just a nursing responsibility. ROD will usually be the link between the bedside and higher
level care.
· Once rapid response team is called, the team will assist the management in collaboration with treating consultant and/or his
registrar during the phase of instability.

Patient Monitoring:
MODIFIED ADULT EARLY WARNING SCORING SYSTEM
· This scoring system has been designed to help nursing staff to identify patients who are becoming seriously ill.
· It should be used on every adult patient after their observations have been done.

Score 3 2 1 0 1 2 3
HR <40 41-50 51-100 101-110 111-130 >130
BP (Systolic) <70 71-80 81-100 101-179 180-199 200-220 > 220
Respiratory Rate <8 8- 11 12- 20 21- 25 26- 30 >30
- RR
Temperature(°C) <34 34.0-35.0 35.1-37.5 37.6-38.5 38.6-40.0 >40
Urine In last 2 <30 80-120 120-200 > 800
hours/mls
Oxygen <85% 86-89% 90-94% >95%
Saturations
Resp Support / Bi-pap / Hi-flow Oxygen Therapy
Oxygen Therapy CPAP
Central Nervous Confusion Awake Responds Responds Unresponsive
System –CNS & Responsive to Verbal to Painful
Command Stimuli

· Each measurement is given a score from the table above. If the patient’s total score is 4 or more, senior help must be sought. The
patient should be assessed and further help sought from the Rapid Response Team if thought necessary by the patient’s consultant or
his registrar.
· If the patient’s score is less than 4 but their condition is causing concern, help should be sought from the immediate senior in
the usual way.
o The point of this scoring system is that an expectation exists to call for a help if the score is 4 or more.

CRITICAL ILLNESS INDICATOR ( Inform Physician Immediately)

BREATHING
· Respiratory Rate of 8 or 25 per minute
· Oxygen saturations of 90% despite up to 60% inspired oxygen
CIRCULATION
· Pulse of 40 or 130 per minute
· Systolic blood pressure of 90 mmHg or 200 mmHg

RENAL
· Oliguria – urine output 30 mls/hour for three consecutive hours

CENTRAL NERVOUS SYSTEM

· Only responds to painful stimuli or is unresponsive

RAPID RESPONSE TEAM

Definition:
· Rapid Response Team is a multidisciplinary team responsible for evaluation of patients not in the ICU/OR/ER who develop signs
or symptoms of clinical deterioration.
· Modified Adult Early Warning is a scoring system designed to help staff identify patients who are becoming seriously ill.
Purpose:
· To facilitate enhanced assessment of patients at risk by highlighting and responding to clinical triggers
· To proactively treat "pre arrest" adult inpatients effectively and thereby decrease inpatient mortality rates.
· To decrease hospital code rate.
Roles/Responsibilities/Accountabilities
· All Clinical staff should be trained to recognize and respond to a patient whose condition appears to be worsening.
· Based on the hospital’s early warning criteria, staff seeks additional assistance when they have concerns about a patient’s
condition.
· Clinical staff in charge of the patient should inform the patient and family how to seek assistance when they have concerns about a
patient’s condition.
Rapid Response Team members:
1. ICU Registrar
2. Nurse Supervisor
3. Respiratory Therapist (RT)
4. Registrar on Duty (ROD)
5. Area Manager
Policy:
· The EBH uses the Modified Early Warning Scoring System with periodic observation of selected vital sign values
· When one or more extreme vital signs values are noted, a predefined action is taken according to the flow diagram ( Modified Adult
EWSS Flow Chart )
· Activate Rapid Response Team by Phone # 1111 for adult
· The Rapid Response Team will be available to respond immediately once activated like the Code Blue Team.
· The Rapid Response Team is not there to permanently take over and assume care of the patient; the role of the team is to bring
critical care expertise to the bedside.
· The team shall review the patient within 5 minutes.

This policy does not encompass Do Not Resuscitate (DNR) orders.

Criteria for Activation ( refer PPP 084 # MSP XXX-XXX-011) as per policy:
Ø Any staff member (nurse, physical therapist, respiratory therapist, physician) is worried about the patient.
Ø Acute change in heart rate <40 or >130 bpm
Ø Acute change in systolic blood pressure <90 mm/hg
Ø Acute change in respiratory rate <8 or >30 per minute
Ø Acute change in saturation <90 percent despite 02
Ø Acute change in conscious status
Ø Acute change in urinary output <30 ml in less 2 hours

Additional Criteria:
Ø Chest pain unrelieved by nitroglycerin Ø Seizure
Ø Threatened airway Ø Uncontrolled pain.

Procedure:
1. Staff nurse assesses the patient and compare findings with the clinical criteria (refer to Modified Adult ESWW).
2. Any staff member may page/bleep the ROD of the admitting consultant and the Rapid Response Team if the patient’s total score is 4 or
more.
3. The Rapid Response team in collaboration with the ward nurse assesses the patient, assist in the calling of consultant, implementing
orders and transferring as necessary.
4. Rapid Response team develops a medical directive to allow RRT members to order basic blood work, ECG, chest x-ray, and to allow
Respiratory Therapists to perform an ABG, prior to contacting the physician
5. Protocols will be applied according to standing orders.
6. Most common Interventions that Rapid Response team must undertake ( or call others to undertake) include:
Nasopharyngeal / Oropharyngeal suctioning and additional oxygen
IV line insertion
Administration of an IV fluid bolus
Administration of an IV furosemide (Lasix) bolus
Initiation of non-invasive positive pressure ventilation
Initiation of nebulized beta-agonists (albuterol, for example)
Arterial line insertion
Score 3 2 1 0 1 2 3
HR <40 41-50 51-100 101-110 111-130 >130
BP (Systolic) <70 71-80 81-100 101-179 180-199 200-220 > 220
Respiratory Rate <8 8- 11 12- 20 21- 25 26- 30 >30
- RR
Temperature(°C) <34 34.0-35.0 35.1-37.5 37.6-38.5 38.6-40.0 >40
Urine In last 2 <30 80-120 120-200 > 800
hours/mls
Oxygen <85% 86-89% 90-94% >95%
Saturations
Resp Support / Bi-pap / Hi-flow Oxygen Therapy
Oxygen Therapy CPAP
Central Nervous Confusion Awake Responds Responds Unrespon
System –CNS & Responsive to Verbal to Painful
Command Stimuli
Endotracheal intubation
CVP insertion
Initiation of Emergency Medication
7. ICU registrar shall relay the RRT patient status to ICU consultant on call.
8. Follow up shall be conducted by treating physician’s ROD within 1 hour.
9. Nursing staff shall follow up patient’s vital signs at least hourly for 4-6 hours.

Education and Training:

1. Advanced critical care training ( ACLS)
2. SBAR (Situation, Background, Assessment, Recommendation) method of communicating and receiving communications about patient
condition
3. Communication skills, including responding in a professional and friendly manner (“Thank you for calling. How can I help you?”)
4. Appropriate expectations, including responding in a timely manner (e.g., within 10 minutes every time the Rapid Response Team is
called); providing non-judgmental, non-punitive feedback to the person that initiated the call to the Rapid Response Team; providing a
learning opportunity for the caregiver

Education and training of Nursing Staff:

1. The person who activates the Rapid Response Team is a key member of the team.
2. The Rapid Response Team is not there to take over and assume care of the patient; the role of the team is to bring critical care expertise to the bedside.
3. Criteria and procedures for activating, how to notify the team
4. Communication and teamwork skills – use of SBAR, appropriate assertion, and critical language skills
5. Activation expectations – call even if you’re unsure. (“If you are worried, so are we.”)
6. Staff (Rapid Response Team and staff activating the Rapid Response Team) are to keep the focus on the patient. This is not the time for criticism or judgment.
7. Have information available for the team, such as the chart, medication administration record (MAR), previous assessments, etc.

Patient and Family Education:

Educate patient and family regarding warning signs that a patient is getting much sicker:
· Changes in the heart or respiratory (breathing) rate
· A drop in blood pressure (it gets much lower)
· Changes in urinary output (much more or much less urine)
· Confusion or other mental status (thinking) changes
· When something just does not look or seem right with the patient
Nurse Action ( Indicated in the revised Observation Sheet)
Score of 2 – Monitor Vital Signs hourly
Score of 3 – Inform ROD, monitor vital signs every 30 minutes
Score of 4 – Activate RRT

References:

PPP 093#MSP 003-014-091

PPP 094#MSP 004-014-092

Name: ________________________________________________ SCORE:____________

ID No.:_______ Department: _________

EARLY WARNING SCORING SYSTEM and RAPID RESPONSE TEAM

1) What is the minimum score in activating RRT?
a) 3 or more d) 5 or less
b) 3 or less e) 2 or more
c) 5 or more
2) What is the most sensitive indicator of patient’s psychological wellbeing?
a) Respiratory Rate
b) Heart Rate
c) Blood Pressure
d) Temperature
Score 3 2 1 0 1 2 3
Heart rate < 40 41-50 51-100 101-110 111-130 > 130
Blood Pressure (Systolic <70 71-80 81-100 101-179 180-199 200-220 > 220
Respiratory Rate <8 8-11 12-20 21-25 26-30 > 40
Temperature (⁰C ) <34 34.0 – 35.0 35.1-3705 37.6-38.5 38.6-40.0 > 40
Urine output in the last 2 hours <30ml 80-120ml 120-200ml >800ml
Oxygen saturations <85% 86-89% 90-94% >95%
Oxygen Therapy / Support Bi-pap Hi-flow O2 therapy
Awake & Responds to Responds to
Central Nervous Sytsem Confusion Unresponsive
Responsive verbal stimuli painful stimuli
e) Obesity

Use the EWSS Chart to guide your analysis of the scenarios and answer the questions that follow:
3) Mrs. Mathena, a 56 year old mother admitted in OB ward post cesarian section has been assessed by the nurse and vital signs
showed: BP (96 / 45 mmHg), RR: 30 per minute, Temp.: 37⁰C, SPO2: 89% on room air Urine output: Total of 180ml for 2 hours
She is conscious but exhibits anxiety.
a) What is the early warning score:________________________________________________
b) Will you active RRT? ------------- Yes  No 
c) What is the code for activation? ________________

4) Mr. Youngfellow, a 50 year old male, married, obese, has been admitted in Telemetry and had undergone Coronary Angiography
wherein stents have been placed on his 2 coronary arteries. He called the Nurse and has been complaining of chest pain.
Vital signs showed:
BP: 120/69 CR:68 beats per minute Temp: 36.6⁰C
Urine Output: < 30ml for 2 hours; on O2 of 2L per nasal cannula
He is conscious.Nitroglycerin sublingual has been given for a total doses but the pain score persisted on a score of 7 – 8/10.
a) What is the early warning score?______________________________________________________
b) Will you activate RRT? ------------- Yes  No 
c) If yes, are/is there any other criteria / criterion that made you activate RRT? ___________________

5) Early warning systems rely on obsertvations of the physiological status of the patient, reflecting a clinical evaluation of:
a) Vital signs
b) Oxygen delivery
c) Laboratory results
d) Organ perfusion
e) B and D
FIVE POINTS OF SAFE SURGERY CHECK