This guideline exists to give a consistent approach to recognising the unwell or deteriorating patient. It has standardised triggers based on events or physiological parameters for escalating concerns. These triggers are defined to give an early warning in addition to clinical judgement.
Recognising patient deterioration is particularly important for prolonged patient contact such as long distance transfers or extended transfer of care situations, and continual re-assessment is vital.
Track and Trigger systems are widely used in health care to predict acute deterioration. SJWA has adopted Early Warning Score based tools to produce a score based on physiological parameters (observations), with defined triggers at certain threshold scores.
This guideline aligns to the Recognising and Responding to Acute Deterioration standard under the National Safety and Quality Health Service standards.
Early Warning Scores should be calculated for all patients (unless otherwise obviously time critical), and re-calculated when conducting further routine observations.
Clinical judgement should always be used based on the patient’s presenting complaint and history. Patients may present with signs or symptoms of concerning pathology that do not generate an early warning score (for example: cardiac pattern chest pain, unstable arrythmias, stroke) and should be managed and escalated as clinically appropriate regardless of their Early Warning Score.
Adults 16 years and over
NEWS2 (National Early Warning System) is a standardised scoring system based on physiological parameters. It is validated for prehospital use for adult patients and gives a better matched acuity because of the combination of parameters. It has triggers based on the total Early Warning Score (EWS).
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|---|
| Respiratory Rate | ≤4 | 5‑8 | 9‑11 | 12‑20 | 21‑24 | ≥25 | ||
| SpO2 % Scale 1 | ≤91 | 92‑93 | 94‑95 | ≥96 | ||||
| SpO2 % Scale 2* | ≤83 | 84‑85 | 86‑87 | 88‑92 ≥93 on RA | 93‑94 on O2 | 95‑96 on O2 | ≥97 on O2 | |
| O2 Therapy L/min | Nil | Any O2 | ||||||
| Heart Rate | ≤30 | 31‑40 | 41‑50 | 51‑90 | 91‑110 | 111‑129 | ≥130 | |
| Systolic BP | ≤70 | 71‑90 | 91‑100 | 101‑110 | 111‑219 | ≥220 | ||
| Level of Consciousness * | Unresponsive | Confused Voice Response Pain Response | Alert | |||||
| Temperature | ≤35.0 | 35.1‑36.0 | 36.1‑38.0 | 38.1‑39.0 | ≥39.1 |
The score for each parameter should be added together to produce a total Early Warning Score.
* The following considerations apply when using NEWS2:
- SpO2 Scale 1 should be used for the majority of patients. Scale 2 should be used only for patients known to have a target SpO2 range of 88-92% as per the Oxygen CPG.
- Level of consciousness should be scored based on an acute change. If a patient has a chronic altered level of consciousness (for example, dementia) and does not have an acute change from their baseline, they should score zero for this parameter.
NEWS2 Calculator
We have developed a calculator to help you calculator the NEWS2 score of your patient that can be applied using the physiological parameters outlined above. Relevant escalation actions based on patients score are listed below
Children under 16 years of age
The Paediatric Acute Recognition and Response Observation Tool (PARROT) has been introduced as a standard across Western Australia for paediatric patients (under 16) in acute care settings. An early warning score (EWS) is calculated based on physiological parameters relevant to the patient's age as well as points for Family/Clinician Concern.
There are five aged-based charts.
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|---|
| Family/Clinician Concern * | No | Yes | ||||||
| Respiratory Distress | Nil | Mild | Moderate | Severe | ||||
| Respiratory Rate | ≤20 | 21-25 | 26-30 | 31-60 | 61-65 | 66-74 | ≥75 | |
| SpO2 % | ≤85 | 86-88 | 89-91 | ≥92 | ||||
| O2 Therapy (L/min) | ≤2 | >2-5 | >5-10 | ≥10 | ||||
| Heart Rate | ≤70 | 71‑90 | 91-100 | 101-110 | 111-160 | 161-170 | 171-179 | ≥180 |
| Systolic BP | ≤40 | 41‑50 | 51‑60 | 61‑70 | 71‑100 | 101-110 | 111-119 | ≥120 |
| Capillary Refill Time | <2 sec | 2-3 sec | ≥4 sec | |||||
| Pain | 0-3 | 4-6 | 7-10 | |||||
| Level of Consciousness (AVPU) | Unresponsive | Pain | Voice | Alert | ||||
| Temperature (°C) * | ≤35.9 Consider Sepsis | 36.0-37.9 | ≥38.0 Consider Sepsis | |||||
The score for each parameter should be added together to produce a total Early Warning Score, then the corresponding actions to the score in the escalation pathway below should be followed. Any observation in the purple 'E' area should trigger an immediate emergency response regardless of any other score.
* The following considerations apply when using PARROT:
- Family/Clinician Concern: Ask if the parents or caregivers are concerned their child is deteriorating.
- Respiratory Distress: Score the highest criteria obtained in the Paediatric Respiratory Distress Assessment table.
- Pain score: Verbal numeric score, FLACC or Faces scale as per Pain Assessment guideline.
- Temperature: Does not contribute to Early Warning Score, however any patient with temperature out of range should have an immediate sepsis assessment as per Sepsis CPG, regardless of total EWS
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|---|
| Family/Clinician Concern * | No | Yes | ||||||
| Respiratory Distress | Nil | Mild | Moderate | Severe | ||||
| Respiratory Rate | ≤15 | 16-20 | 21-25 | 26-55 | 56-65 | 66-74 | ≥75 | |
| SpO2 % | ≤85 | 86-88 | 89-91 | ≥92 | ||||
| O2 Therapy (L/min) | ≤2 | >2-5 | >5-10 | ≥10 | ||||
| Heart Rate | ≤70 | 71‑80 | 81-90 | 91-100 | 101-160 | 161-170 | 171-179 | ≥180 |
| Systolic BP | ≤50 | 51‑60 | 61‑70 | 71‑75 | 76‑120 | 121-125 | 126-129 | ≥130 |
| Capillary Refill Time | <2 sec | 2-3 sec | ≥4 sec | |||||
| Pain | 0-3 | 4-6 | 7-10 | |||||
| Level of Consciousness (AVPU) | Unresponsive | Pain | Voice | Alert | ||||
| Temperature (°C) * | ≤35.9 Consider Sepsis | 36.0-37.9 | ≥38.0 Consider Sepsis | |||||
The score for each parameter should be added together to produce a total Early Warning Score, then the corresponding actions to the score in the escalation pathway below should be followed. Any observation in the purple 'E' area should trigger an immediate emergency response regardless of any other score.
* The following considerations apply when using PARROT:
- Family/Clinician Concern: Ask if the parents or caregivers are concerned their child is deteriorating.
- Respiratory Distress: Score the highest criteria obtained in the Paediatric Respiratory Distress Assessment table.
- Pain score: Verbal numeric score, FLACC or Faces scale as per Pain Assessment guideline.
- Temperature: Does not contribute to Early Warning Score, however any patient with temperature out of range should have an immediate sepsis assessment as per Sepsis CPG, regardless of total EWS
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|---|
| Family/Clinician Concern * | No | Yes | ||||||
| Respiratory Distress | Nil | Mild | Moderate | Severe | ||||
| Respiratory Rate | ≤10 | 11-15 | 16-20 | 21-40 | 41-50 | 51-54 | ≥55 | |
| SpO2 % | ≤85 | 86-88 | 89-91 | ≥92 | ||||
| O2 Therapy (L/min) | ≤2 | >2-5 | >5-10 | ≥10 | ||||
| Heart Rate | ≤60 | 61‑70 | 71-80 | 81-90 | 91-140 | 141-160 | 161-169 | ≥170 |
| Systolic BP | ≤50 | 51‑60 | 61‑70 | 71‑80 | 81‑120 | 121-129 | ≥130 | |
| Capillary Refill Time | <2 sec | 2-3 sec | ≥4 sec | |||||
| Pain | 0-3 | 4-6 | 7-10 | |||||
| Level of Consciousness (AVPU) | Unresponsive | Pain | Voice | Alert | ||||
| Temperature (°C) * | ≤35.9 Consider Sepsis | 36.0-37.9 | ≥38.0 Consider Sepsis | |||||
The score for each parameter should be added together to produce a total Early Warning Score, then the corresponding actions to the score in the escalation pathway below should be followed. Any observation in the purple 'E' area should trigger an immediate emergency response regardless of any other score.
* The following considerations apply when using PARROT:
- Family/Clinician Concern: Ask if the parents or caregivers are concerned their child is deteriorating.
- Respiratory Distress: Score the highest criteria obtained in the Paediatric Respiratory Distress Assessment table.
- Pain score: Verbal numeric score, FLACC or Faces scale as per Pain Assessment guideline.
- Temperature: Does not contribute to Early Warning Score, however any patient with temperature out of range should have an immediate sepsis assessment as per Sepsis CPG, regardless of total EWS
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|---|
| Family/Clinician Concern * | No | Yes | ||||||
| Respiratory Distress | Nil | Mild | Moderate | Severe | ||||
| Respiratory Rate | ≤5 | 6-10 | 11-15 | 16-35 | 36-45 | 46-49 | ≥50 | |
| SpO2 % | ≤85 | 86-88 | 89-91 | ≥92 | ||||
| O2 Therapy (L/min) | ≤2 | >2-5 | >5-10 | ≥10 | ||||
| Heart Rate | ≤50 | 51-60 | 61-70 | 71-80 | 81-140 | 141-160 | 161-169 | ≥170 |
| Systolic BP | ≤50 | 51‑60 | 61‑70 | 71‑80 | 81‑120 | 121-129 | ≥130 | |
| Capillary Refill Time | <2 sec | 2-3 sec | ≥4 sec | |||||
| Pain | 0-3 | 4-6 | 7-10 | |||||
| Level of Consciousness (AVPU) | Unresponsive | Pain | Voice | Alert | ||||
| Temperature (°C) * | ≤35.9 Consider Sepsis | 36.0-37.9 | ≥38.0 Consider Sepsis | |||||
The score for each parameter should be added together to produce a total Early Warning Score, then the corresponding actions to the score in the escalation pathway below should be followed. Any observation in the purple 'E' area should trigger an immediate emergency response regardless of any other score.
* The following considerations apply when using PARROT:
- Family/Clinician Concern: Ask if the parents or caregivers are concerned their child is deteriorating.
- Respiratory Distress: Score the highest criteria obtained in the Paediatric Respiratory Distress Assessment table.
- Pain score: Verbal numeric score, FLACC or Faces scale as per Pain Assessment guideline.
- Temperature: Does not contribute to Early Warning Score, however any patient with temperature out of range should have an immediate sepsis assessment as per Sepsis CPG, regardless of total EWS
| Score | E | 3 | 2 | 1 | 0 | 1 | 2 | 3 | E |
|---|---|---|---|---|---|---|---|---|---|
| Family/Clinician Concern * | No | Yes | |||||||
| Respiratory Distress | Nil | Mild | Moderate | Severe | |||||
| Respiratory Rate | ≤5 | 6-10 | 11-15 | 16-30 | 31-35 | 36-39 | ≥40 | ||
| SpO2 % | ≤85 | 86-88 | 89-91 | ≥92 | |||||
| O2 Therapy (L/min) | ≤2 | >2-5 | >5-10 | ≥10 | |||||
| Heart Rate | ≤40 | 41-50 | 51-60 | 61-120 | 121-130 | 131-139 | ≥140 | ||
| Systolic BP | ≤60 | 61-70 | 71-80 | 81-90 | 91-150 | 151-170 | 171-190 | 191-199 | ≥200 |
| Capillary Refill Time | <2 sec | 2-3 sec | ≥4 sec | ||||||
| Pain | 0-3 | 4-6 | 7-10 | ||||||
| Level of Consciousness (AVPU) | Unresponsive | Pain | Voice | Alert | |||||
| Temperature (°C) * | ≤35.9 Consider Sepsis | 36.0-37.9 | ≥38.0 Consider Sepsis | ||||||
The score for each parameter should be added together to produce a total Early Warning Score, then the corresponding actions to the score in the escalation pathway below should be followed. Any observation in the purple 'E' area should trigger an immediate emergency response regardless of any other score.
* The following considerations apply when using PARROT:
- Family/Clinician Concern: Ask if the parents or caregivers are concerned their child is deteriorating.
- Respiratory Distress: Score the highest criteria obtained in the Paediatric Respiratory Distress Assessment table.
- Pain score: Verbal numeric score, FLACC or Faces scale as per Pain Assessment guideline.
- Temperature: Does not contribute to Early Warning Score, however any patient with temperature out of range should have an immediate sepsis assessment as per Sepsis CPG, regardless of total EWS
A patient meeting an Early Warning Score trigger based on the age-appropriate EWS above, or any clinical criteria listed in the below table, should an escalation of care and immediate actions as per the below escalation table.
ALL PATIENTS |
|
AMBER ESCALATION |
|
Or any clinical trigger not immediately correctable:
| |
RED ESCALATION |
|
Or any clinical trigger not immediately correctable:
| |
| Likely to deteriorate rapidly | |
EMERGENCY ESCALATIONAny single observation in PURPLE (E) area |
|
Or any clinical trigger not immediately correctable:
| |
| Immediately life-threatening critical illness | |
- Transport to an Emergency Department should be advocated for any patient meeting any escalation level due to the potential for deterioration
- Consider if patient has Advanced Health Directive or other end of life care plan that may modify management or response to deterioration.
- This guideline is not intended to overrule Withholding or Termination of Resuscitation
- Consider potential causes of patient deterioration, such as sepsis, arrhythmia, hypovolemia/haemorrhage, PE/DVT, pneumonia, MI, stroke or overdose/oversedation and manage accordingly.
NEWS2 Reproduced from: Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP, 2017
ESCALATION System developed and owned by Curtin University & Child and Adolescent Health Service. PARROT images ©2021 Child and Adolescent Health Service.
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