Early warning
By Kathy D. Duncan, RN; Christine McMullan, MPA; and
Barbara M. Mills, DNP, PNP, RN, ACNPC, ANPC, CCRN, PCCN
CARDIAC ARRESTS in hospitals are
usually preceded by observable signs
of deterioration, which often appear
2.3 6 to 8 hours before the arrest occurs.
ANCC
CONTACT HOURS Studies suggest many patients ex-
hibit signs and symptoms of medical
deterioration that go untreated prior
to a cardiac arrest.1-4 Schein et al.
found that 84% of patients had doc-
umented observations of clinical de-
terioration or new complaints within
8 hours of cardiopulmonary arrest;
in 70% of patients, deterioration of
either respiratory or mental function
was observed during this time.1
Hodgetts et al. noted that 17% of
cardiac arrests occurred in patients
38 l Nursing2012 l February
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
who were being cared for in an in-
appropriate clinical area.5 Cardiac
arrest was potentially avoidable in
95% of those patients; in contrast,
it was potentially avoidable in 60%
of patients cared for in appropriate
areas.5
In 2004, the Institute for Health-
care Improvement (IHI) launched
the 100,000 Lives Campaign in an
effort to rapidly and dramatically
improve patient outcomes. IHI is
a not-for-profit organization whose
mission is to improve the safety,
effectiveness, patient-centeredness,
timeliness, efficiency, and equity
of care delivery. IHI identified six
www.Nursing2012.com
g systems
strategies aimed at saving 100,000
lives in U.S. hospitals:
1. Deploy rapid response teams.
2. Improve care for acute myocardial
infarction.
3. Prevent adverse drug events.
4. Prevent central line infections.
5. Prevent surgical site infections.
6. Prevent ventilator-associated
pneumonia.6
One of the campaign’s six inter-
ventions was to support hospitals
in deploying rapid response teams.
As a result of this and other quality
initiatives, many hospitals across
the United States developed rapid
response systems in an effort to reduce
www.Nursing2012.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The next
level of
rapid
response
cardiac arrests and other sudden life-
threatening events.
Rapid response systems include
processes of event detection, re-
sponse triggering, response process
improvement, and an administra-
tive structure.7 Rapid response
systems empower staff and family
members to quickly summon a
designated group of critical care
clinicians to the bedside to evaluate
a patient’s worsening condition.
The team can intervene to treat the
acutely ill patient at the bedside,
or the team may assist in the im-
mediate transfer of the patient to
an ICU.
Room for improvement
In general, intervention by a rapid
response team in the United States is
triggered by one aspect of a patient’s
condition at a time, typically an ex-
treme change in a particular vital
sign. For example, a significant rise
or drop in BP or a significant change
in respiratory rate (for example, ei-
ther below 10 or above 30 breaths
per minute) would trigger a call.
While this single-aspect approach
has been effective, what if organiza-
tions could identify at-risk patients
even before such an extreme change?
What if a system could respond to
multiple aspects of a patient’s condition
February l Nursing2012 l 39
at the same time and identify at-risk
patients at the first sign of a subtle
change in vital signs?
A few hospitals have moved to
implement such systems through an
early warning scoring (EWS) system.
The EWS system and rapid response
systems have been associated with
significant reductions in both cardiac
arrests and unscheduled admissions
to the ICU.8
IHI recently finished a virtual web
series, called an Expedition, to coach
hundreds of organizations on how to
implement these systems. The key
points learned from this work and
the story from one exemplar hospital
are outlined here.
How EWS works
An EWS is a physiologic scoring
system typically used in general
medical-surgical units before patients
experience a catastrophic medical
event. This scoring is accompanied
by a descriptive step-by-step guide
or algorithm of actions to take based
on the patient’s assessment score.
An EWS can add another layer of
early detection to the rapid response
team system, helping staff recognize
high-risk patients before their condi-
tion deteriorates.4,9,10 Although the
idea of an EWS is still relatively new
in the United States, this concept is
being successfully applied in many
hospitals in the United Kingdom.4,10,11
Developing an EWS
Stony Brook University Medical Cen-
ter (SBUMC), a New York State hos-
pital in Long Island, comprises Stony
Brook University School of Medicine
and Stony Brook University Hospital.
SBUMC is the only tertiary care hos-
pital and Level 1 trauma center in
Suffolk County. SBUMC currently
has 591 beds, including 58 in adult
critical care and 52 in pediatric and
neonatal critical care.
SBUMC implemented its rapid
response team in December 2005,
first testing it on a small scale (during
40 l Nursing2012 l February
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Each color of the pediatric
early warning scoring
system requires the nurse
to complete a designated
series of actions.
one shift in one unit) and then ex-
panding it when the organization
deemed the initiative successful. The
rapid response team initiative was
fully deployed throughout the hos-
pital (24 hours a day, 7 days a week)
by February 2007. Our rapid re-
sponse team consists of an NP or
medical resident, a critical care nurse,
and a respiratory therapist.
After developing the rapid response
team, however, SBUMC found that
not all at-risk patients were being
identified; nurses didn’t have a com-
plete set of criteria to identify a failing
patient early and trigger a call to the
team. Staff began to look for ways to
improve the initiative.
SBUMC staff members first learned
of successful implementation of a
pediatric EWS (PEWS) system at a
National Institute for Children’s
Healthcare Quality conference in
March 2007. A presentation by Cin-
cinnati Children’s Hospital indicated
that the implementation of its PEWS
system decreased mortality, length of
stay, and code blue events outside
the ICU. Cincinnati Children’s Hos-
pital adapted and applied a PEWS
assessment tool originally developed
by Royal Alexandra Hospital for Sick
Children in Brighton, England.12
Staff attending the session brought
the tools developed by Cincinnati
Children’s Hospital back to SBUMC
and suggested testing similar tools in
our pediatric units.
After our staff modified the PEWS
tool obtained at the conference for
SBUMC use, the general pediatric
unit tested it during the summer of
2007 (see Pediatric Early Warning
Score [PEWS]). The PEWS tool moni-
tored three physiologic indicators:
behavioral, cardiovascular, and respi-
ratory. We added a grid identifying
age-appropriate limits for hypoten-
sion to the tool to make the cardio-
vascular indicator assessment more
accurate.
The direct care nurse or clinical
assistant (the unlicensed assistive per-
sonnel or UAP) determines the PEWS
score and obtains vital signs every
4 hours. The UAP collects patient
vital signs and the direct care nurse
ensures the accuracy of PEWS assess-
ment. The nurse scores each indicator
according to a specific behavior or
range of vital signs. Each physiologic
indicator is assigned a score, ranging
from 0 to 3, depending on the assess-
ment outcome. A score of 0 is consid-
ered normal or acceptable. Scores
ranging from 1 to 3 are considered
abnormal or unacceptable.
Scores for all indicators are added
to create the PEWS score. The total
PEWS score is assigned a color based
on the sum of these numbers: a total
of 0 to 2 is green, 3 is yellow, 4 is
orange, and 5 or higher is red.
We developed an algorithm/
process flow diagram to depict the
actions required based on the result-
ing color. Each color requires the
nurse to complete a designated series
of action items. This algorithm en-
sures standardization in the applica-
tion of the patient assessment and
adequate communication of the
patient’s score. It also validates the
www.Nursing2012.com
decision by the nurse to contact the
patient’s attending healthcare pro-
vider or the rapid response team dur-
ing off hours. If at any time the at-
tending healthcare provider doesn’t
respond within 10 minutes of the
page, the nurse is directed to call the
rapid response team for assessment
and treatment of the patient.
Here are the actions mandated by
each color:
• A yellow score requires the reas-
sessment of the patient by the charge
nurse on duty. If the charge nurse
confirms that the score is accurate,
he or she determines whether inter-
vention is required, documents as-
sessment and intervention in the
medical record, and reassesses the
patient within 2 hours.
• An orange score requires reassess-
ment by the charge nurse and notifi-
cation of the first- or second-year
medical resident. The resident alerts
the senior resident and attending
healthcare provider of the change in
the patient’s medical condition, and
medical staff takes appropriate ac-
tion. The direct care nurse reassesses
the patient within 1 hour.
• A red score requires notification of
the rapid response team and resident.
The resident alerts the senior resident
and attending healthcare provider,
who are all expected to respond to the
patient’s bedside. The rapid response
team and primary care team collabo-
rate on the patient’s plan of care. The
direct care nurse reassesses the patient
within 1 hour.
Documentation and
communication
Around the time we were testing the
EWS, SBUMC was involved in the
implementation of its electronic medi-
cal record (EMR). We agreed to docu-
ment the PEWS assessment by writing
in the hybrid paper medical record
during this testing phase. This allowed
us to modify the assessment tool more
quickly and limit the resources de-
voted to the electronic build of the
assessment until we finalized the tool.

Pediatric Early Warning Score (PEWS)

Color and Number Coding PEWS

0 1 2 3 SCORE
BEHAVIOR Appropriate Inappropriately Irritable Lethargic/Confused
Quiet OR Reduced
Green = 0–2 Score
response to pain

CARDIO- Pink or Pale or Grey or Capillary Grey and mottled or

VASCULAR Capillary Capillary refill 3
refill 4 seconds OR capillary refill 5
refill 1-2 seconds Tachycardia of 20 seconds or above OR
seconds above normal rate Tachycardia of 30 Yellow = 3 Score
above normal rate or
Systolic blood Systolic blood
bradycardia
pressure10mm Hg pressure 20mm Hg
above or below above or below
age-appropriate age-appropriate
Orange = 4 Score
limit limit
RESPIRATORY Within > 10 above > 20 above 5 below normal
normal normal normal parameters with
parameters, parameters, parameters with retractions and/or
no using accessory retractions. grunting. Red = ≥ 5 Score
retractions muscles

Age-appropriate limits for hypotension

Age Group Systolic Blood Pressure, mm Hg
Newborn – 30 days ≤ 60
1 mo – < 1 yr ≤ 70
≥ 1 year – < 10 yrs ≤ 70 + 2× (age in years)
≥ 10 yrs < 90

Adapted and reprinted with permission from Stony Brook University Medical Center.
Adapted from: Royal Alexandra Hospital for Sick Children, Brighton-Paediatric Early Warning Score

www.Nursing2012.com February l Nursing2012 l 41

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 To assist with communication of
the PEWS, SBUMC purchased a mag-
netic white board to hang on the wall
at the nursing station. Room num-
bers were posted on the white board
instead of patient names to ensure
privacy. Color magnets placed on the
board in the appropriate space pro-
vided a display of the patient score,
allowing a quick, “at a glance” view
of the unit’s acuity level and helping
in the assignment of patients to nurs-
es on the unit. Soon after testing, we
agreed that resident-to-resident hand-
offs for patients with an orange or red
score would take place at the bedside
to provide timely knowledge of at-risk
patients on the unit.
We implemented the PEWS initia-
tive on our remaining pediatric unit,
a hematology/oncology unit, in the
fall of 2007.
Extending the initiative to
adult patients
After deploying the PEWS in all
our pediatric units, we developed a
modified EWS (MEWS) system for
use with our adult patients (see Modi-
fied Early Warning System [MEWS]).
We measured these physiologic ele-
ments in our MEWS: respiratory
rate, heart rate, systolic BP, level of
consciousness, and temperature.
Compared with PEWS, the MEWS
assessment was more complicated
because it incorporated aspects
above and below the normal or ac-
ceptable range. We also expanded
the algorithm for responding to the
MEWS score to include reassess-
ment by the direct care nurse every
hour for 4 consecutive hours to
ensure patient stability. If the patient
didn’t remain stable for 4 consecu-
tive hours, the team considered
transferring the patient to a higher
level of care.
We also developed an assessment
tool and an algorithm and applied
them to our obstetric patients
(OB-EWS) in early 2008. Following
the lessons learned from testing the
PEWS on the pediatric units, we
documented the scores manually
in the hybrid paper medical record
and posted the scores on a magnetic
white board on the wall at the nurses’
station.
Although the PEWS/MEWS as-
sessment tool was generally deemed
appropriate by the direct care nurses
and nurse managers, staff members
believed the tool identified a high
incidence of inappropriate yellow
and orange scores, which required
the charge nurse to reassess the
patient.
We conducted a prevalence study
in November 2007 to determine
common triggers for the yellow
scores and the actions required as
a result. In this study, we reviewed
the medical records of 10 random
patients on each unit over a 24-hour
period for accuracy of their scores
and whether the identified algo-
rithm had been followed. The study
showed that 52% of the patients
with an elevated MEWS had an
altered respiratory rate. Further

Modified Early Warning System (MEWS)

3 2 1 0 1 2 3
Green = 0-1
Respiratory Less than 8 9-17 18-20 21-29 ≥ 30 Score
rate per 8
minute
Heart rate Less than 40-50 51-100 101-110 111-129 ≥ 130
per minute 40 Yellow = 2-3
Score
Systolic ≤ 70 71-80 81-100 101-159 160-199 200-220 > 220
blood
pressure
Conscious Unrespon- Responds Responds Alert Agitation New onset Orange = 4-5
level (AVPU) sive to pain to voice or of agitation Score
confusion or confusion

Temperature < 95.0˚ F 95.0-96.8˚ F 96.9-100.4˚ F 100.5-101.3˚ F ≥ 101.4˚ F

(35.0˚ C) (35.05-36˚ C) (36.05-38˚ C) (38.05-38.5˚ C) (38.55˚ C)
Red = ≥6
Score

Adapted and reprinted with permission from Stony Brook University Medical Center.

42 l Nursing2012 l February www.Nursing2012.com

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
analysis of the data demonstrated
that the clinical assistants had in-
accurately assessed the respiratory
rate. RNs’ observation of clinical
assistants during vital signs collec-
tion revealed an opportunity for
increased education on the correct
technique of measuring respiratory
rate.
We conducted another preva-
lence study in January 2008 to re-
assess the tool and to assess staff
accuracy in using it. The incidence
of altered respiratory rate trigger-
ing the elevated score dropped to
29%, and accuracy in staff assess-
ment of the patient was measured
at 99.1%.
Once we finalized our PEWS and
MEWS tools, we worked with our
information technology department
to build the screen into our EMR.
SBUMC staff worked with the ven-
dor to develop an electronic assess-
ment screen that pulled vital signs
into the assessment form and tallied
the EWS score. The screen also high-
lighted required actions for the ab-
normal scores, such as “alert rapid
response team.”
About 1 year after the initial phase
of the EWS initiative, we decided all
orange and red scores would auto-
matically generate a text page to the
rapid response team director. When
the director receives a red score, a
patient assessment is required. An
orange score prompts the director to
call the patient’s unit to offer assis-
tance. This systematic change greatly
increased the number of rapid re-
sponse team calls triggered each
month.
We’re also testing early warning
scores in the automated screening of
severe sepsis in our general medical
units. The scores include altered vital
signs and mental status—signs of
severe sepsis. We’re working with
our information technology staff
to develop a method of pulling the
EWS into an automated severe sepsis
screening process. This process is in
www.Nursing2012.com
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
All orange and red scores
automatically generate a text
page that’s sent to the rapid
response team director.
its infancy. Two of our medical units
are currently testing it to assess ef-
ficacy and accuracy.
Barriers and shortcomings
Our EMR system prohibits the nurse
from easily entering vital signs and
EWS scores at the bedside. Although
computers on rolling carts are avail-
able, many nurses document their
assessments in the computer at the
nursing station, contributing to a
delay in process flow and timely
documentation. Placing color mag-
nets on the white board to indicate a
change in the score creates an added
step and causes delays.
Ideally, providing pocket computers
to our nursing staff to document the
patient’s EWS and vital signs would
encourage a more efficient process. An
electronic board depicting the unit’s
collective EWS scores would also im-
prove efficiency. We need to explore
alternate funding sources so we can
implement this automated process.
Although we fully instituted the
rapid response team in 2007, we
continue to hear of incidents where
the healthcare providers criticize the
nursing staff for calling the rapid
response team because of the team’s
concerns about the patient. Auto-
matically paging the rapid response
team for orange and red EWS scores
eliminates the hesitance of the nurs-
ing staff to initiate a rapid response
team call.
Results of instituting system
Code blue calls outside of the pediat-
ric and neonatal ICU decreased post-
implementation. Twenty-one codes
were called in 2008, compared with
15 codes in 2009, and 9 codes for
the first two quarters of 2010. Inciden-
tally, analysis of length of stay and
mortality after implementation didn’t
reveal an improvement from the
baseline period.
Reviewing adult rapid response
team data for 2007 to 2010 revealed
a modest decrease in the number
of code blue calls as the number of
rapid response team calls increased.
The number of rapid response team
calls over this period grew from 361
in 2007 to 1,225 in 2010. Conse-
quently, the percentage of codes
occurring outside of ICUs decreased
from 51.67% in 2007 to 47.33% in
2010.
Our number of rapid response
team calls remains constant at 100
calls per month. Rapid response
team calls increased significantly
when we initiated an automated
alpha page to the rapid response
team director for all orange and red
EWS scores. The rapid response
team director assesses these patients
to determine if intervention is re-
quired and proceeds accordingly.
This automated notification and
required follow-up is perceived by
the rapid response team as extreme-
ly valuable in the prevention of fur-
ther patient decline.
Improving patient outcomes
A standardized acuity assessment
and communication method to rec-
ognize and avoid patient decline may
reduce patient mortality and length
February l Nursing2012 l 43
of stay. Standardization increases
reliability and decreases variation in
the delivery of patient care. Develop-
ing a standardized tool to assess the
patient and corresponding algorithm
or guide of action steps ensures reliable
delivery of patient care. For pediatric
patients, the observed-to-expected
mortality dropped slightly post-
implementation as did the average
length of stay. Unfortunately, a de-
crease in adult length of stay and
observed-to-expected mortality
wasn’t realized. All mortalities are
reviewed to determine opportunities
for improvement and are brought to
the appropriate quality venue for
execution. Our staff believes EWS to
be beneficial in the early recognition
and prevention of further patient
decline, and we continue to evaluate
the system and collect data. ■
REFERENCES
1. Schein RM, Hazday N, Pena M, Ruben BH,
Sprung CL. Clinical antecedents to in-hospital
cardiopulmonary arrest. Chest. 1990;98(6):
1388-1392.
2. Franklin C, Mathew J. Developing strategies
to prevent in hospital cardiac arrest: analyzing
responses of physicians and nurses in the hours
before the event. Crit Care Med. 1994;22(2):
244-247.
3. Buist M, Bernard S, Nguyen TV, Moore G, An-
derson J. Association between clinically abnormal
observations and subsequent in-hospital mortality:
a prospective study. Resuscitation. 2004;62(2):
137-141.
4. Gardner-Thorpe J, Love N, Wrightson J, Walsh
S, Keeling N. The value of Modified Early Warning
Score (MEWS) in surgical out-patients: a prospec-
tive observational study. Ann R Coll Surg Engl.
2006;88(6):571-575.
5. Hodgetts TJ, Kenward G, Vlachonikolis IG,
Payne S, Castle N. The identification of risk factors
for cardiac arrest and formulation of activation
criteria to alert a medical emergency team. Resusci-
tation. 2002;54(2):125-131.
6. Institute for Healthcare Improvement. Overview
of the 100,000 Lives Campaign. http://www.ihi.
org/offerings/Initiatives/PastStrategicInitiatives/5M
illionLivesCampaign/Documents/Overview%20
of%20the%20100K%20Campaign.pdf.
7. DeVita MA, Bellomo R, Hillman K, et al. Finding
of the first consensus conference on medical emer-
gency teams. Crit Care Med. 2006;34(9):2463-2478.
8. Moon A, Cosgrove JF, Lea D, Fairs A, Cressey
DM. An eight year audit before and after the intro-
duction of modified early warning score charts, of
patients admitted to a tertiary referral intensive care
unit after CPR. Resuscitation. 2011;82(2):150-154.
9. Morgan RJM, Williams F, Wright MM. An early
warning scoring system for detecting developing
critical illness. Clin Intensive Care. 1997;8:100.
10. Higgins Y, Maries-Tillott C, Quinton S, Rich-
mond J. Promoting patient safety using an early
warning scoring system. Nurs Stand. 2008;22(44):
35-40.
11.Gao H, McDonnell A, Harrison DA, et al. Sys-
temic review and evaluation of physiological track
and trigger warning systems for identifying at-risk
patients on the ward. Intensive Care Med. 2007;33(4):
667-679.
12. Akre M, Finkelstein M, Erickson M, Liu M,
Vanderbilt L, Billman G. Sensitivity of the pediatric
early warning score to identify patient deteriora-
tion. Pediatrics. 2010;125(4):e763-e769. Epub 2010
Mar 22.
Kathy D. Duncan is faculty at the Institute for Health-
care Improvement in Cambridge, Mass. At Stony
Brook University Medical Center in Stony Brook, N.Y.,
Christine McMullan is the director of continuous
quality improvement, and Barbara M. Mills is the
director of the rapid response team.
The authors wish to acknowledge the gracious assis-
tance of William H. Greene, MD, chief quality officer
and senior associate medical director for quality; and
data managers David Harris, MS, CPHQ, and Sandra E.
Martich, MS.
The authors and planners have disclosed that they
have no financial relationships related to this article.
DOI-10.1097/01.NURSE.0000410304.26165.33

> For more than 15 additional continuing education articles related to

safety topics, go to NursingCenter.com/CE. <
Earn CE credit online:
Go to http://www.nursingcenter.com/CE/nursing and
receive a certificate within minutes.

Early warning systems: The next level of rapid response
TEST INSTRUCTIONS
• To take the test online, go to our secure website at
http://www.nursingcenter.com/ce/nursing.
• On the print form, record your answers in the test
answer section of the CE enrollment form on page 45.
Each question has only one correct answer. You may
make copies of these forms.
• Complete the registration information and course
evaluation. Mail the completed form and registration
fee of $21.95 to: Lippincott Williams & Wilkins, CE
Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will
mail your certificate in 4 to 6 weeks. For faster service,
include a fax number and we will fax your certificate
within 2 business days of receiving your enrollment
form.
• You will receive your CE certificate of earned contact
hours and an answer key to review your results. There
is no minimum passing grade.
• Registration deadline is February 28, 2014.
INSTRUCTIONS
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins
together by mail, and deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other healthcare facilities on nursingcenter.
com. Call 1-800-787-8985 for details.
PROVIDER ACCREDITATION
Lippincott Williams & Wilkins, publisher of Nursing2012 journal, will award 2.3 contact hours
for this continuing nursing education activity.
Lippincott Williams & Wilkins is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s Commission on Accreditation.
Lippincott Williams & Wilkins is also an approved provider of continuing nursing
education by the District of Columbia and Florida #FBN2454. This activity is also provider
approved by the California Board of Registered Nursing, Provider Number CEP 11749 for
2.3 contact hours.
Your certificate is valid in all states.
The ANCC’s accreditation status of Lippincott Williams & Wilkins Department of Continuing
Education refers only to its continuing nursing educational activities and does not imply
Commission on Accreditation approval or endorsement of any commercial product.

44 l Nursing2012 l February www.Nursing2012.com

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.