ADULT EARLY WARNING SIGNS.xlsx

	A	B	C	D	E	F	H	O	R	W	AE
1										PATIENT IDENTIFICATION LABEL
2
3							ADULT EARLY WARNING SIGNS
4							ADULT EARLY WARNING SIGNS
5
6	EWS KEY ADMISSION DATE:
7	0	1	2	3	DATE				SCORE		DATE
8					TIME				SCORE		TIME
9	A+B Resprations breaths/min				≥30				3		≥30
10					26-30				2		26-30
11					21-25				1		21-25
12					12-20						12-20
13					9-11				1		9-11
14					≤8				3		≤8
15
16	A+B Oxygen Saturation %				≥95						≥95
17					90-94				1		90-94
18					86-89%				2		86-89%
19					≤85				3		≤85
20
21	Air or Oxygen				A=Air						A=Air
22					O2 L/Min				2		O2 L/Min
23					Device						Device
24
25					≥220				3		≥220
26	Blood Pressure mmhg Scores uses systolic BP only				201-210						201-210
27					191-200						191-200
28					171-180				2		171-180
29					161-170				2		161-170
30					151-160				1		151-160
31					141-150				1		141-150
32					121-140						121-140
33					111-120						111-120
34					101-110				1		101-110
35					91-100				2		91-100
36					81-90				2		81-90
37					61-70				3		61-70
38					51-60						51-60
39					≤50						≤50
40
41	C				≥131				3		≥131
42					121-130				2		121-130
43					111-120				2		111-120
44	Pulse Beats/min				101-110				1		101-110
45					91-100						91-100
46					81-90						81-90
47					71-80						71-80
48					61-70						61-70
49					51-60						51-60
50					46-50				1		46-50
51					41-45				2		41-45
52					≤40				3		≤40
53
54	D Conciousness Score for NEW onset of Confusion (no score if Chronic)				A						A
55					Confusion				3		Confusion
56					V						V
57					P						P
58					U						U
59
60	E Temperature				≥38.4				2		≥38.4
61					37.3-38.4				1		37.3-38.4
62					36.5-37.2						36.5-37.2
63					35.1-36.4				1		35.1-36.4
64					≤35°				2		≤35°
65
66	EWS Score
67
68	Blood Sugar
69	Pain Score
70	Urine Output Monitoring
71	Monitoring Frequency
72	Escalation of Care Y/N
73	Initials
74	REFERRAL ALGORITHM
75	SCORE					FREQUENCY OF MONITORING		CLINICAL RESPONSE
76	0					Minimum 12 hourly		Continue routine EWS monitoring with every set of observations
77	1-4					Minimum 4-6 hourly		• Increase frequency of monitoring and / or decide for escalation of clinical care is required Treat as clinically appropriate
78	5-7 OR 1 in Parameter					Increased frequency to a minimum of 1 hourly		• Registered nurse to urgently inform the medical team caring for the patient; • Urgent assessment by a clinician with core competencies to asses acutely ill patients; • Clinical care in an environment with monitoring facilities; Consider transfer to ICU
79	7 OR More					continuous monitoring of vital signs		• Registered nurse to immediately inform the medical team caring for the patient - this should be at least at Specialist Registrar level; notify intensivist • Emergency assessment by a clinical team with critical care competencies, which also includes a practitioner/s with advanced airway management skills; • Consider transfer of Clinical care to a level 2 or 3 care facility, Transfer to ICU • Activate Code Blue
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