UNCONTROLLED WHEN PRINTED
 Purpose

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.

 Physiological Parameters

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 *UnresponsiveConfused
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

NEWS2 calculator


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. There are five sets of physiological parameters based on the patient's age. Like the adult system, it has triggers based on the total Early Warning Score (EWS).

There are five aged-based charts.


Score E 3 2 1 0 1 2 3
Family/Clinician Concern *    NoYes  
Respiratory Distress    NilMildModerateSevere
Respiratory Rate ≤2021-25 26-3031-6061-6566-74≥75
SpO2 %
≤85
86-8889-91≥92   
O2 Therapy (L/min)    ≤2>2-5>5-10≥10
Heart Rate ≤7071‑90 91-100101-110111-160161-170171-179≥180
Systolic BP ≤40 41‑50 51‑6061‑7071‑100101-110111-119≥120
Capillary Refill Time    <2 sec2-3 sec≥4 sec 
Pain    0-34-67-10 
Level of Consciousness (AVPU)Unresponsive
PainVoiceAlert   
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 *    NoYes  
Respiratory Distress    NilMildModerateSevere
Respiratory Rate ≤15
16-2021-2526-5556-6566-74≥75
SpO2 %
≤85
86-8889-91≥92   
O2 Therapy (L/min)    ≤2>2-5>5-10≥10
Heart Rate ≤7071‑80 81-9091-100101-160161-170171-179≥180
Systolic BP ≤50 51‑60 61‑7071‑7576‑120121-125126-129≥130
Capillary Refill Time    <2 sec2-3 sec≥4 sec 
Pain    0-34-67-10 
Level of Consciousness (AVPU)Unresponsive
PainVoiceAlert   
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 *    NoYes  
Respiratory Distress    NilMildModerateSevere
Respiratory Rate ≤1011-1516-20 21-4041-5051-54≥55
SpO2 %
≤85
86-8889-91≥92   
O2 Therapy (L/min)    ≤2>2-5>5-10≥10
Heart Rate ≤6061‑70 71-8081-9091-140141-160161-169≥170
Systolic BP ≤50 51‑60 61‑7071‑8081‑120121-129 ≥130
Capillary Refill Time    <2 sec2-3 sec≥4 sec 
Pain    0-34-67-10 
Level of Consciousness (AVPU)Unresponsive
PainVoiceAlert   
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 *    NoYes  
Respiratory Distress    NilMildModerateSevere
Respiratory Rate ≤56-1011-15 16-3536-4546-49≥50
SpO2 %
≤85
86-8889-91≥92   
O2 Therapy (L/min)    ≤2>2-5>5-10≥10
Heart Rate ≤5051-6061-7071-8081-140141-160161-169≥170
Systolic BP ≤50 51‑60 61‑7071‑8081‑120 121-129≥130
Capillary Refill Time    <2 sec2-3 sec≥4 sec 
Pain    0-34-67-10 
Level of Consciousness (AVPU)Unresponsive
PainVoiceAlert   
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 *    NoYes   
Respiratory Distress    NilMildModerateSevere 
Respiratory Rate ≤5
6-1011-1516-3031-3536-39≥40 
SpO2 %
≤85
86-8889-91≥92    
O2 Therapy (L/min)    ≤2>2-5>5-10≥10 
Heart Rate ≤4041-50 51-6061-120121-130131-139≥140  
Systolic BP ≤60 61-7071-8081-9091-150151-170171-190191-199 ≥200
Capillary Refill Time    <2 sec2-3 sec≥4 sec  
Pain    0-34-67-10  
Level of Consciousness (AVPU)Unresponsive
PainVoiceAlert    
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

 


 Escalation Thresholds/Triggers and Actions

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
EWS 0-4

  • A-E assessment at first practical opportunity
  • Full set of observations
  • Regular observations - increase frequency of observations if EWS increasing
  • Document all assessment, actions or escalation attempts and outcome

AMBER ESCALATION
EWS 5-6

Or any single observation in RED (score 3) area

Or  Amber flag sepsis criteria

  • Re-assess A-E and initiate appropriate clinical care
  • Increase frequency of observations
  • Consider Sepsis using appropriate screening tool
  • Patient Transport/LAR/Event Health Services/Volunteer Ambulance Officers: consult with SOC CSP, or call for paramedic backup where available, recommended
  • Extended Transfer of Care: request re-assessment – state patient meets Amber Escalation Criteria and requires triage review and detail any concerns

Or any clinical trigger not immediately correctable:

  • Increasing oxygen requirement
  • Poor peripheral circulation
  • BSL < 4mmol/l or >20mmol/l with no decrease in level of consciousness
  • Concern by attending clinician
Acute illness or unstable chronic disease, at risk of deterioration

RED ESCALATION
EWS 7+

Or  Red flag sepsis criteria

  • Re-assess A-E and initiate appropriate clinical care
  • Continuous cardiac monitoring (where available) and pulse oximetry along with increased frequency of observations
  • Consider Sepsis using appropriate screening tool
  • Consider Priority 1 transport
  • Consider requirement for additional resources
  • Patient Transport/LAR/Event Health Services/Volunteer Ambulance Officers: consult with SOC CSP, or call for paramedic backup where available, required
  • Extended Transfer of Care: request urgent medical review - state patient meets Red Escalation Criteria and requires urgent medical review and detail any concerns

Or any clinical trigger not immediately correctable:

  • Partial airway obstruction or stridor
  • Increasing oxygen requirements to maintain oxygen saturation >90%
  • Only responds to pain on AVPU scale
  • Sudden decrease in level of consciousness (drop of 2 or more points on GCS)
  • BSL < 4mmol/l or > 20mmol/l with decrease in level of consciousness
  • Acute behavioural disturbance with severe agitation (RASS 4)
  • Serious concern by clinician
Likely to deteriorate rapidly

EMERGENCY ESCALATION

Any single observation in PURPLE (E) area

  • Re-assess A-E and initiate appropriate resuscitative care
  • Priority 1 transport if not correctable
  • Consider requirement for additional resources
  • Patient Transport/LAR/Event Health Services/Volunteer Ambulance Officers: consult with SOC CSP, or call for paramedic backup where available, required
  • Extended Transfer of Care: activate hospital's emergency procedure for immediate care - state patient meets Emergency Escalation Criteria and requires immediate management and detail clinical concerns

Or any clinical trigger not immediately correctable:

  • Cardiac or respiratory arrest
  • Complete airway obstruction
  • Patient unresponsive
  • Generalised seizure activity
  • Significant uncontrollable haemorrhage
  • Any other time critical event of serious concern to clinician
Immediately life-threatening critical illness
 Considerations
  • 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.

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Version

Published Date

Review Date

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