《早期预警评分》

Early Warning Score (EWS)PurposeUse of an Early Warning Score (EWS) assists with the recognition and appropriate response to the patient at risk of clinical deterioration as well as a clinically deteriorating patient. The EWS is a support to skilled clinical assessment, decision making and plan of care.An Early Warning Score must be used for all patients within a hospital setting when recording vital signs for: •Early detection of detrimental changes.•Safe, timely, effective management of care in response to a patient’s deteriorating condition. The EWS is to be communicated between staff when transferring patients between areas and with requests for clinical assistance.Specialist areas that do not use EWS routinely are required to calculate an EWS for safe transfer.Vital signs observation charts will contain the appropriate EWS tool.Types of early warning scores in use•The New Zealand Early Warning Score (NZEWS) is a nationally standardised scoring tool designed for adults. For the present the NZEWS is intended for adult non-maternity patients only.•Maternity patients use The New Zealand National Maternity Early Warning System (MEWS). The MEWS should be used for all pregnant women of any gestation including up to 6 weeks after birth.•Paediatric patients up to 15 years of age, use the age appropriate Paediatric EWS (PEWS).•Neonates; babies born in CWH and CDHB primary birthing units use the new-born Observation Chart (NOC) which incorporates the New-born Early Warning Score (NEWS).•For the purposes of this policy when the term EWS is used, this encompasses the EWS, MEWS, PEWS, NEWS.ApplicabilityAll CDHB or contracted clinical staff (e.g. Agency nursing staff, Lead Maternity Carers with CDHB access agreement).DefinitionsEarly Warning Score ParametersAdult patientsFor an adult patient, the following observations/symptoms must be recorded to obtain an accurate NZEWS: •Respiratory rate calculated over 1 minute•Presence or absence of oxygen therapy•Oxygen saturation % (SpO2)•Heart rate for at least ½ minute•Blood pressure using appropriate cuff and calibrated equipment•Level of consciousness using AVPU (alert, voice, pain, unresponsive)•Temperature (using a consistent site and method)Pregnant women (of any gestation including up to 6 weeks after birth)For a maternity patient, the following observations / symptoms must be recorded to obtain an accurate MEWS:•Respiratory rate calculated over 1 minute•Supplemental oxygen administration(L/min)•Oxygen saturation % (SpO2)•Heart rate for at least ½ minute•Blood pressure•Temperature (using a consistent site and method)•Level of consciousness (normal or abnormal)Paediatric patientsFor a paediatric patient the following observations / symptoms must be completed on admission to obtain accurate PEWS. Subsequent observation requirements are determined by the PEWS management plan, the Nursing Observations and Monitoring Policy [Ref 239155] and/or as indicated by the paediatric medical team.•Respiratory rate calculated over 1 minute•Respiratory distress score•Oxygen saturation % (SpO2)•Heart rate for at least ½ minute•Blood pressure•Level of consciousness using AVPU (alert, voice, pain, unresponsive)•Capillary refill timeNote: Whilst temperature is not included in the PEWS, a baseline temperature recording is taken on admission and four hourly thereafter for an inpatient if within normal limits.NeonatesFor neonates during the immediate post-natal period (1-2 hours) post birth and then at 24 hours, the following should be observed and recorded on the New-born Observation Chart and a NEWS calculated: •Respiratory rate calculated over 1 minute•Work of Breathing•Temperature•Heart rate calculated over a minute•Colour•Behaviour / FeedingAll babies should be assessed against the risks for deterioration as outlined on the New-born Observation Chart and if identified to be at risk then observations and NEWS are performed as instructed and care escalated as required.Education and trainingAll staff within the scope of this procedure must have completed relevant clinical training on the EWS score, escalation and response.Education should be guided by the EWS decision tree.Early Warning Score Procedure Clinical staff responsibilitiesClinical staff responsibilitiesAll patients must have a clinically appropriate plan of care documented, including frequency of monitoring of vital signs, any limitations or ceiling of care and any modification to the response pathway.Staff must be able to perform their responsibilities within this procedure.1.Recognition: Activation1.1.Provide adequate privacy and ensure informed consent1.2.Take the vital signs using appropriate techniques, where applicable inform the patient or caregiverof the results and recording appropriate EWS, check for EWS triggers, and in the absence of Patientrack calculate thescore and record.1.4.Check clinical record for relevant treatment goals and/or plan of care1.5.If escalation pathway triggered, activate according to the response pathway zone colour andfollow plan.1.6.Care for patient, record and act on vital signs as per the EWS zone colour and clinical protocolswhile awaiting review.1.7.Record activation in clinical progress notes or where Cortex is available on the PatientDeterioration Form.1.8.For adults (except maternity), use of the NZEWS activation template is mandatory if a clinicalreview is requested.1.9.For maternity patients, use of the Activation of MEWS Pathway sticker (Ref: 2311278,) or digitalequivalent whenever discussion or further review is requested.Note: The EWS does not replace clinical judgement. Should a clinician or family member be concerned in the absence of a high EWS consider medical review. Within inpatient areas where Kōrero Mai – Patient Family Escalation has been implemented, staff are to support families with escalating care at their request and responding as applicable.2.Response: Escalation2.1.Respond according to the escalation pathway, clinical plans and clinical judgement2.2.Record the response in the clinical notes (using the appropriate response template):a.The EWS triggers and zoneb.Date and time of reviewc.Assessment, decisions and management plan including vital sign frequency (if contrary tothe EWS pathway recommendations) , follow up, higher level of care needs, treatmentlimitations and ceiling of cared.Staff notified and consultede.If a follow up review is required, indicate the timeframe for the review to prevent furtherpatient clinical deterioration.f.If a Senior Medical Officer or Registrar modifies the EWS, the reason is recorded, and themodification must be reviewed by the patient’s Home Team in the am the next day (12noon at the latest).munication / handover/ transfer of care requirementsAny pathway communication / handover or transfer of care with other staff is provided using ‘Identity, Situation, Background, Assessment, Response’ (ISBAR) communication method stating the:a.Patient’s condition / diagnosisb.Patient’s EWSc.The parameters that drove the scored.The actions already been takene.Repeat back the plan of action to take following the communication i.e. repeat EWS in settimeframe and contact medical staff again as required.Measurement / EvaluationUse of early warning system One System Dashboard in clinical governance meetings; regular audit of adherence of the EWS system conducted in areas using the CDHB EWS / MEWS / PEWS / NEWS Audit tool; inclusion in morbidity and mortality meetings.Evaluation can be guided by the EWS decision tree.Associated materialCDHB Resources:•Transfer of patients between hospitals.•ISBAR handover / communication policy.•Deteriorating Patient Activation and Response form document (Ref: 2406526)or digital equivalent Healthlearn•Deteriorating Patient Course (DP001)•New Zealand Early Warning Score•Paediatric Early Warning Score (PE001)•MEWS – Maternity Early Warning Score (RGMY001)•New-born Observation Chart with new-born Early Warning Score (RGMY002)NZEWS Zone / Score (Ref: 2403999) (Appendix 1)NZEWS site specific pathways (Appendix 2)•Christchurch Ref: 2405744•Burwood Ref: 2405791•Hillmorton Ref: 2404730•Ashburton Ref: 2406302PEWS pathway (Appendix 5)Nursing Observation and Monitoring - Paediatrics (Ref: 2405195)EWS decision tree (Appendix 3)MEWS site specific pathways (Appendix 4)•Christchurch Women’s Hospital (Maternity, Birthing Suite, Maternity Assessment Unit, Women’s Outpatient Department) (Ref: 2406285)•Primary Units (Ashburton, Lincoln, Kaikoura, Darfield, Rangiora) (Ref: 2406474)•St. Georges maternity Ref: (2406789)•Activation of MEWS Pathway sticker (Ref: 2404638)•Minimum Frequencies of Observations for Maternity Early Warning Score (MEWS) Chart (Ref: 2404636)NOC/NEWS (Appendix 6)•CDHB New-born Observation Chart 6676 (Ref: 2401230)•CDHB New-born Record QMR0044 (Ref: 2400438)•Observation of mother and baby in the immediate postnatal period: consensus statements guiding practice, MOH, (July 2012)Kōrero Mai - Patient Family Escalation - “Are you Concerned” Signage (Ref: 2407406, 2406997, ,2406998. Shared Goals of Care Document (Ref: 2406924)Appendix One: NZEWS Zone calculatorAppendix two: CDHB NZEWS site specific response pathwaysAppendix three: EWS decision treeAppendix four: Modified Early Obstetric Warning (MEWS) Management Protocol Score and management/responseChristchurch Women’s Hospital(Maternity, Birthing Suite, Maternity Assessment Unit, Women’s Outpatient Department)CDHB Primary Community Maternity Units (Ashburton, Lincoln, Kaikoura, Darfield, Rangiora)St. George’s Maternity UnitAppendix five: Paediatric Early Warning Score (PEWS) Management Protocol Score and management / responseAppendix six: Guide of When to use the New-born Observation Chart and NEWSContentsEarly Warning Score (EWS) (1)Purpose (1)Types of early warning scores in use (1)Applicability (1)Definitions (1)Adult patients (1)Pregnant women (of any gestation including up to 6 weeks after birth) (2)Paediatric patients (2)Neonates (2)Education and training (2)Early Warning Score Procedure Clinical staff responsibilities (3)Clinical staff responsibilities (3)1.Recognition: Activation (3)2.Response: Escalation (3)munication / handover/ transfer of care requirements (4)Measurement / Evaluation (4)Associated material (4)CDHB Resources: (4)Healthlearn (4)Appendix One: NZEWS Zone calculator (5)Appendix two: CDHB NZEWS site specific response pathways (6)Appendix three: EWS decision tree (10)Appendix four: Modified Early Obstetric Warning (MEWS) Management Protocol Score and management/response (11)Christchurch Women’s Hospital (11)CDHB Primary Community Maternity Units (Ashburton, Lincoln, Kaikoura, Darfield, Rangiora) (12)St. George’s Maternity Unit (13)Appendix five: Paediatric Early Warning Score (PEWS) Management Protocol Score and management / response (14)Appendix six: Guide of When to use the New-born Observation Chart and NEWS (15)。

病患初期预警等级(NEWS)量表
评分标准如下：
呼吸频率：正常范围为12-20次/分钟，超出范围加分。

血压：正常范围为90-140 mmHg（收缩压）和60-90 mmHg （舒张压），超出范围加分。

心率：正常范围为60-100次/分钟，超出范围加分。

体温：正常范围为36°C-37.5°C，超出范围加分。

意识状态：正常意识加0分，有意识障碍加分。

吸氧情况：不需吸氧加0分，需吸氧加分。

根据以上指标进行评分后，将各项分数累加得出总分。

总分越高代表患者病情越严重，需要更紧急的干预措施。

评分等级如下：
总分0-4分：稳定，不需要特别干预。

总分5-6分：轻度恶化，需密切观察。

总分7-8分：中度恶化，需加强监测和干预。

总分9分及以上：重度恶化，需立即采取紧急措施。

病患初期预警等级(NEWS)量表是一个简单而有效的工具，可帮助医护人员快速评估患者病情变化情况，及早采取适当的干预措施，以确保患者安全和健康。

早期预警评分评估与护理快速准确地评估患者病情是临床工作的重要环节，通常患者在出现急性病情变化之前会发生潜在的生命体征的改变，如心率、血压、呼吸频率、体温及意识水平等，及时而有效的干预可以明显改善临床预后。

在疾病恶化早期，采用早期预警评估系统监测评估能早期发现患者潜在的病情变化，可为病情恶化提供预防措施,早期预警评分（Early Warning Score，EWS）是一种简单、易行的评估工具。

一、定义及相关概念早期预警评分（Early Warning Score，EWS）：1997年由英国Morgan等首先提出，是一种快速识别危重症或潜在危重症患者病情的评分系统，通过对患者各项生理参数(血压、心率、呼吸、体温、意识)进行观察并赋值，将所有参数评分相加得到EWS评分，根据事先规定的触发值，有效地帮助临床医护人员快速识别危重症或潜在危重症患者。

经过不断改良，临床使用较多的是改良早期预警评分（Modified Early Warning Score，MEWS）、国家早期预警评分（National Early Warning Score，NEWS）和儿童早期预警评分(Pediatric Early Warning Score，PEWS)。

1.改良早期预警评分（Modified Early Warning Score，MEWS）：2001年Subbe等对早期预警评分进行改良，并命名为改良早期预警评分，将其作为一种用于急诊急救系统和ICU患者评估病情、预测危险分层的方法。

2.国家早期预警评分（National Early Warning Score，NEWS）：2012年英国皇家医师学会在MEWS的基础上制定了统一的早期预警评分标准，并命名为国家早期预警评分，NEWS 在MEWS基础上，对各项生命体征指标做出调整，并增加是否氧疗和血氧饱和度评分。

将其作为一个标准化的判断疾病严重程度、早期识别危重病患者、持续监测病情变化的工具。

早期预警评分系统MEWS
简介
早期预警评分系统（Modified Early Warning Score，MEWS）
是一种用于评估病人病情变化程度的工具。

通过监测患者的生命体
征和指标，并根据得分系统对数据进行评估，MEWS能够帮助医生和护士及时发现病人可能出现的急性恶化情况，并采取相应的医疗
干预措施。

工作原理
MEWS评分系统一般包括以下几个生命体征指标：血压、心率、呼吸速率、体温和意识状态。

每个指标根据其数值范围不同，对应
不同的分数。

将这些指标得分相加后，就可以得到一个总评分，根
据总评分的高低判断患者病情的危险程度。

评分范围与危险程度
MEWS评分系统的不同得分范围对应着患者病情的不同危险程度。

一般来说，评分越高，患者的病情越危险。

医疗工作者可以根
据患者的总评分，及时采取必要的护理和治疗措施。

应用
MEWS评分系统广泛应用于医院的急诊科、重症监护室等部门，用于对患者进行监测和预警。

医生和护士可以通过定期进行MEWS 评分，系统地记录和分析患者的生命体征变化，从而早期发现病情
的恶化趋势，采取相应的干预措施，提高病人的治疗效果和生存率。

总结
早期预警评分系统（MEWS）是一种简单而有效的工具，可帮
助医生和护士在病人病情恶化之前及时发现并采取措施。

通过监测
患者的生命体征指标并进行评估，MEWS评分系统可以帮助医疗工作者提高病人的治疗效果，降低不良事件的发生率。

病情危重早期预警
临床工作中患者的病情总是在不断变化，其中部分可能会变化成危重情况。

早期识别、及时发现，对于早期干预、早期治疗，为抢救工作赢得宝贵时间。

这里推荐一份改良的早期预警表格，临床医护可根据患者体温、脉搏、血压、呼吸、意识状态、尿量、脉搏氧饱和度和血糖水平等指标，对患者情况进行初步评估，对早期发现可疑危重患者提供支持。

为进一步处置赢取时机。

2.严重程度分级，根据评分可客观地将患者分为轻、重、危3个等级：
2.1.轻病：评分0~4分；
2.2.重病：评分5~8分；
2.3.危重病：评分≥9分。

3.临床意义：
3.1.早期预警评分4~5分是鉴别患者病情严重程度的最佳临界点；
3.2.早期预警评分﹤5分多不需要住院治疗；
3.3.早期预警评分≥5分病情恶化的可能性大，多需要住院治疗；
3.4.早期预警评分≥9分死亡的危险性明显增加；
3.5.单项评分3分或总分大于5分均应引起重视。

4.注意：识别困难的重症患者：①年轻，身体耐受力强，症状体征出现可能较晚。

②一些免疫抑制剂应用者应激反应差，临床表现常不明显。

③创伤患者出现复合伤、多发伤可能性大，容易遗漏重要损伤情况。

④某些特殊疾病如严重的心律失常，脑出血等，可在短时间内突然加重，而之前往往缺少上述预测指标的改变。

病患早期预警评级(NEWS)量表
简介
病患早期预警评级(NEWS)量表是一种用于评估病患病情稳定性的工具。

该量表通过检测患者的临床指标，帮助医护人员及早发现患者可能存在的危机情况，以便采取适当的干预措施。

量表内容
病患早期预警评级(NEWS)量表包含以下七个指标：
1. 呼吸频率
2. 血氧饱和度
3. 意识水平
4. 收缩压
5. 脉搏
6. 温度
7. 人体质量指数（BMI）
每个指标都有相应的分级标准，用于判断患者的病情稳定程度。

医护人员需要根据患者的实际情况，对每个指标进行测量，并将得
分累加得到最终的预警评级。

使用方法
使用病患早期预警评级(NEWS)量表时，医护人员应按照以下
步骤进行：
1. 针对每个指标，测量患者的具体数值。

2. 根据每个指标的分级标准，判断该指标在哪个等级范围内。

3. 将每个指标的等级转换成相应的分数。

4. 将各指标得分累加，得到最终的预警评级。

医护人员应根据预警评级的结果，决定是否需要采取进一步的
干预措施，如加强监测、调整治疗方案或寻求专业意见。

结论
病患早期预警评级(NEWS)量表是一种可靠的工具，可帮助医
护人员及早发现患者病情的不稳定性。

正确使用该量表可以提高对
患者的监测和干预效果，从而改善患者的治疗结果。

请注意，病患早期预警评级(NEWS)量表只作为辅助工具使用，医护人员仍需综合考虑患者的整体情况和临床判断，做出准确的治
疗决策。

病人早期预警评分(NEWS)量表
国家早期预警评分（NEWS）是一种用于评估患者病情严重程度的工具，该工具的参数包括收缩压、心率、呼吸频率、体温和氧饱和度。

测量氧饱和度时，需要考虑是否正在接受氧疗，如果是，则加2分。

评分结果分为1-4分、5-6分或任意单项指标达3分、7分及以上三个等级。

在评估过程中，收缩压≤90mmHg、心率≥131次/min、呼吸频率≥25次/min、体温≥39.1°C和氧饱和度≤91%的患者将获得3分的评分。

同时，对声音有反应（A）、清楚的意识状态（A）和对疼痛有反应（V）的患者将获得1分、2分和1分的评分。

根据评分结果，需要触发相应的临床应答。

1-4分的患者监测频率为12小时，5-6分或任意单项指标达3分的患者监测频率为4-6小时，7分及以上的患者需要持续监测并进行护理级别提高或转至ICU病房。

在实际应用中，护士需要评估病情并决定是否提高监测频率，如果评分结果达到5分及以上，则需要通知医生进行评估和治疗。

如果评分结果达到7分及以上，则需要通知高年资医生进行评估并考虑提高护理级别或转至ICU病房。

需要注意的是，在测量氧饱和度时，需要参照XXX（BTS）2008年出版的急诊氧疗使用指南。

早期预警MEWS评分表
护士评估MEWS的临床意义
1.使用科学、客观、实用的评价系统早期识别潜在危重患者
2.急诊：合理分流急诊病人提供依据；低年资医护人员是否需要向上级报告获取指示或请求会诊
3.普通病房：病人在普通病房是否需要进行监护或转ICU
4.ICU：通知医生观察病人，做出是否需要处理的决定
危急症的早期预警
•护士：是否需要提高监护级别和报告医生；是否需要通知医生观察、处理病人或转ICU
•医生：是否需要向上级报告获取指示或请求会诊
根据评估分值来决定是否需要进一步评估/或直接干预。