Patient Deterioration: Early Warning Signs

By Bette Case di Leonardi, PhD, RN-BC, Contributor

Patient Deterioration: Early Warning SignsIt is not uncommon for hospitalized patients to exhibit early warning signs before deteriorating. The key to optimal outcomes is recognition of these warning signs followed by an appropriate and timely response. Have you ever called the Rapid Response Team (RRT)? What triggered your call? In most U.S. hospitals, a single warning sign, such as a sudden drop in blood pressure, may trigger a call.

Very often, the feeling that “something is just not right” prompts the call. But is there a way to quantify what might be going wrong in order to address the problem earlier?

Enter the Early Warning Scoring System, or EWSS, which can encourage early intervention, timely transfer to a higher level of care and prevention of codes. EWSS originated in the United Kingdom. Over the last few years, U.S. hospitals have begun to utilize the tool here in the states. Implementing EWSS “adds another layer of early detection to the RRT system” (IHI, n.d.) and allows the healthcare team to intervene earlier.

One widely used version is the Modified Early Warning System (MEWS). Healthcare personnel enter vital signs on a chart form that has red-shaded zones to identify findings outside the normal range for six vital signs, namely: Respiratory rate, heart rate, systolic blood pressure, level of consciousness, temperature and hourly urinary output.

When any one of these signs falls into a red zone, the nurse determines a MEWS score for the patient, assigning a number between 0-3 to each of the six vital signs (as shown in the MEWS algorithm chart, below). The nurse then adds the individual scores for a total MEWS score. If the total score is 4 or higher, the nurse is to call the patient’s provider and alert the RRT

 Click chart for larger view:

MEWS Chart

Hospitals’ protocols and procedures vary in the use of EWSS. Some use the RRT for consultation as well as intervention. Other institutions may not utilize all six of the MEWS parameters, or may modify the tool for specific patient populations such as pediatrics or obstetrics (Duncan, et al., 2012).

In some settings, vital signs entered into the EMR “automatically populate a data warehouse that supports a patient risk tool that includes early warning scores for the previous four days as well as patient lab values for the last eight hours, key medications, and so forth. The patient risk tool also shows graphs of patient vitals for the past 48 hours.” The nurse evaluates these reports and decides whether to call the attending physician, alert the RRT, or continue to monitor the patient (IHI, n.d.). Another teaching hospital color codes their levels of EWSS scores (Duncan, et al., 2012):

• Green = normal
• Yellow requires the charge nurse to reassess.
• Orange requires the charge nurse to reassess and notify the resident.
• Red requires that the nurse notify the RRT and resident.
• Orange or red requires resident-to-resident handoff reporting at the bedside.
Use these early warning signs to detect patient deterioration and gain the benefits of early intervention.

RN.com now offers a new course entitled: The Chain of Command Protects Your Patients and You. This 2 contact hour activity reviews some clinical examples of common risk-for-deterioration scenarios and early warning signs that should be acted upon immediately, and suggests ways in which the nurse can successfully navigate the chain of command to prioritize patient safety.

Duncan, K.D., McMullan, C., & Mills, B.M. (2012). Early warning systems: The next level of rapid response. Nursing2012, 42(2), 38 – 44. Retrieved from here  

Institute for Healthcare Improvement [IHI]. (n.d.) Early warning systems: Scorecards that save lives. Retrieved from here.

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Bette Case Di Leonardi has worked in nursing, education and healthcare administration for more than 40 years and was among the first group of nurses certified in Nursing Professional Development. Today, Di Leonardi is an independent consultant who publishes and presents on a variety of professional and educational topics.