Ali Haedar, MD, SpEM, FAHA

Clinical lecturer & Emergency Medicine Specialist

Department of Emergency Medicine

Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital
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The Need of Early Warning?
— Used to aid recognition of deteriorating patients,
and are based on physiological parameters.

— An aggregated score calculated. Escalation pathway

activated if specific scores. Track and Trigger
approach.

— The escalation pathway outlines actions required for

timely review ensuring appropriate interventions.

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Vital signs to assess
1. Respiratory rate
2. Oxygen Saturations
3. Heart Rate
4. Blood Pressure
5. AVPU/GCS
6. Temp

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1. Respiratory rate
— Relevant in a number of compensatory mechanisms
within the body
— Normal rate should be between 12 and 20.
— The most sensitive indicator of potential
deterioration. Rising rates often early sign.
— Using in conjunction with other evidence ie: use of
accessory muscles, increased work of breathing, able
to speak?, exhaustion, colour of patient.
— Position of patient is important.

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2. Oxygen Saturations
— Blood pumped
from heart is rich
in O2 (95%-99%
saturated)

— Blood pumped
back to heart is
low in O2(65%-
70%)

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Oxygen saturations
— All cells are dependent on an adequate
constant supply of O2 as they are unable
to store it. A reduction can lead to organ
dysfunction and death.

— Dependent on intact respiratory and

cardiovascular function – limited by
other factors ie: peripherally shut down.

— Be aware of patients ‘target saturations’.

— All acutely unwell patients should

receive supplementary Oxygen and then
titrate to readings.

— ABG may be required for more in depth

assessment.
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Oxygen demand
— If oxygen delivery to the
body falls below what is
demanded, the tissues
extract more oxygen
from the haemoglobin
and the saturation of
blood falls.

DO2 = [1.39 x Hb x SaO2 + (0.002 x PaO2)] x CO

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3. Heart Rate
— Should be taken manually
BP = CO x SVR
for one minute, noting the
rate, volume and regularity. CO = SV x HR

— Felt at brachial artery SV = EDV – ESV

— Normal rate can be EDV (preload)
considered 60-100bpm.
ESV (afterload & contractility)
— Abnormal findings need
investigating
— Abnormalities should be
followed with an ECG
— Consider ECG monitoring
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Effects on Heart Rate
— Haemorrhage / bleeding
— Hypotension
— Sepsis
q BP = CO x SVR
— Drugs / medications q CO = SV x HR
— Hypoxia q SV = EDV – ESV
— Temperature q EDV (preload)
— Injury / Insult q ESV (afterload & contractility)
— Electrolytes

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4. Blood pressure
— A LATE sign of deterioration – BP = CO x SVR
patients will compensate (especially
young) CO = SV x HR
— Adequate BP is essential for delivery SV = EDV – ESV
of O2 and nutrients to the rest of the
body. EDV (preload)
— Be aware of what is normal for ESV (afterload & contractility)
patient
— Organs are very dependent on
adequate pressures to ensure
perfusion.
— Manual Blood pressure recording
may be appropriate.

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Blood pressure = pressure on wall of artery
Systolic = pumping pressure
Diastolic = resting pressure

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Pulse Pressure
= Systolic Pressure ─ Diastolic Pressure

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5. Level of Consciousness
— AVPU or GCS for more in depth assessment.
— Consider at what point do you need help?
— This should include drowsiness, agitation, new
changes.
— Assess pupils
— Consider reversible causes ie: blood sugar
— If only responding to pain or unresponsive – airway is
at risk – adult emergency.
— Neuro obs

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6. Temperature
— Can have a significant effect on patients condition.
— High or low can indicate sepsis
— > 38 degrees consider blood cultures
— Significant warming can cause vasodilation
— Low can be as important as high

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Considerations
— O2 needed?
— Positioning
— IV access
— ECG
— Catheter
— IV fluids
— Bloods
— Escalation status

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Who is at risk?
— Any one in hospital!!
— Those with co-existing disease
— All emergency admissions
— Elderly people
— Specific acute illness (sepsis, pancreatitis)
— Those with altered level of consciousness
— Major haemorrhage

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Causes of deterioration
— Sepsis
— Hospital acquired infections
— Chronic disease process
— Co-morbidities
— Failure to manage complications
— Iatrogenic
— Unavoidable complications
— Palliative / end of life

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Rapid response Team (RRT)
— Rapid response Team (RRT) is founded on
the concept of “failure to rescue” or ability
to recognize early signs and symptoms of
deterioration in a patient’s condition to
prevent a severe “adverse event”.
— Adverse event may be defined as an
unintended injury that is due in part to
delayed or incorrect medical management
and that exposes the patient to an increased
risk of death and results in measurable
disability.

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Definition of RRT:
— Also termed a medical emergency team, is a
multidisciplinary team of healthcare providers
who bring critical care level skills to a patient's
bedside in an attempt to avoid further clinical
deterioration and/or cardiopulmonary arrests and
codes.

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— Rapid Response systems aim to improve the safety of
hospital-ward patients whose condition is
deteriorating.
— These systems are based on identification of patients
at risk early notification of an identified set of
responders , rapid intervention by the response team .

Rapid-Response Teams
Daryl A. Jones, M.D., M.B., B.S., Michael A. DeVita, M.D., and Rinaldo Bellomo, M.D., M.B., B.S.
N Engl J Med 2011; 365:139-146, DOI: 10.1056/NEJMra0910926 (NEJM 2011)

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Rapid Response Team
CALL 1234

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Early Warning Score System (or Track and Trigger Score)
A powerful tool used by the care team to identify patients at risk

Example: National Early Warning Score (UK)

x 2
x
1
x
0
2
1
x
3
x
Total 9

x
Dokumentasi Manual
Hari ini, mayoritas rumah sakit menggunakan pencatatan dan perhitungan manual
Intellivue Guardian Solution
MP5 Spot-Check
Mengukur vital signs dan interpretasi EWS
pada saat yang bersamaan
 Intellivue Guardian Solution
Topology
Patient Name
DOB
MRN

NBP
SpO2
RR
Wireless Temp

Database warehouse
Notifications on
Mobile Phone/Tablet
Early warning Score (EWS) systems
— EWS are bedside tools used to assess basic
physiological parameters to identify patients with
potential or established critical illness (Patterson C. at
al, 2011)
— Observational studies suggest that patients often show
signs of clinical deterioration up to 24 hours prior to a
serious clinical event requiring intensive interventions
(Gaughey MJ. at al, 2007)
EWS
— EWS are used by hospital care teams to recognize early
signs of clinical deterioration and trigger more
intensive care, such as increased nursing attention,
informing the care provider, or activating a rapid
response team (RRT) or medical emergency team
(Whittington J at al, 2007)
 HELPS TO
PRIORITIZE CARE

STREAMLINE
COMMUNICATION
EWS
Benefits REDUCE HUMAN
ERROR

RESPONSE RIGHTAT
THE POINT OF CARE
First EWS
— Developed in 1997 by
Morgan et al
— Based on five
physiological
parameters:
— SBP
— Pulse
— Respiratory rate
— Temperature
— AVPU

Morgan et al. Clin Intensive Care 1997;8:100

NICE
— The National Institute for Health and Clinical
Excellence (NICE) have recommended that
physiological track and trigger systems should be used
to monitor all adult patients in acute hospital settings
— Scoring systems used should measure:
— Heart rate
— Respiratory rate
— Systolic blood pressure
— Level of conciousness
— Oxygen saturation
— temperature

NICE Clinical Guideline 50 (2007)

NEWS
— Royal College of
Physicians launched the
NEWS in 2012
— Based on a large number
of vital signs from an
electronic patient
database
— Updated report of
working party, December
2017
Corfield at al. Emerg Med J 2014
Six Simple Physiological Parameters in
the NEWS
 CLINICAL RESPONSE
TO NEWS
• THREE MAIN COMPONENTS

URGENCY OF
CLINICAL
REVIEW

COMPETENCY
OF TEAM

FREQUENCY OF
MONITORING
NEWS SCORING SYSTEM
NEWS 2 SCORING SYSTEM
NEWS Threshold &Trigger
 FREQUENCY OF CLINICAL
MONITORING

• Patients who scored zero should be

monitored every 12 hours
• Scored 1-4 should be monitored every
4-6 hours
• Medium scored patients should be
evaluated hourly
• High score patients should be
continuous monitoring
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EWS have been developed in response to specific
patient types to support local best practice
Name Acronym Description
Designed to support the use of Track
Paediatric Early Warning and Trigger with patients under 16,
PEWS
Score who have different normal ranges for
observations
Designed to support the use of Track
Modified Early Obstetric
MEOWS and Trigger for all women receiving
Warning Score
care from maternity services
Modified to meet the requirements of
Modified Early Warning
MEWS many people in various clinical
Score
situations.
Developed by the Royal College of
National Early Warning NEWS & Physicians to provide a national
Score NEWS2 standard in the UK for Early Warning
Scores (2012 and 2017)
 NEWS and SBAR
— NEWS provides the basis for succinct and efficient
communication about the physiological state of
patients where there is transfer of information
between different professional groups or between
different service providers.
— In combination with communication tools like
SBAR, it is possible to communicate the right
information about patients in a succinct format
that helps to assure a quality communication.

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— Ineffective communication poses a significant
threat to the safety of hospitalized patients.

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EASIER EQUIPMENT TO
MEASURE?
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Early Warning Score System (or Track and Trigger
Score)
A powerful tool used by the care team to identify patients at risk
Example: National Early Warning Score (UK)

x 2
x
1
x
0
2
1
x
3
x
Total 9

x
Dokumentasi Manual
Hari ini, mayoritas rumah sakit menggunakan pencatatan dan perhitungan manual
Intellivue Guardian
Solution
MP5 Spot-Check
Mengukur vital signs dan interpretasi EWS
pada saat yang bersamaan
 Intellivue Guardian Solution
Topology
Patient Name
DOB
MRN

NBP
SpO2
RR
Wireless Temp

Database warehouse
Notifications on
Mobile
Phone/Tablet
Summary
— In hospitals, the EWS should be used for
initial assessment of acute illness and for
continuous monitoring of a patient’s
wellbeing throughout their stay in hospital.
— Likewise, the recording of the EWS trends
will provide guidance about the patient’s
recovery and return to stability, thereby
facilitating a reduction in the frequency and
intensity of clinical monitoring towards
patient discharge.
 INCLUSION CRITERIA FOR
EARLY WARNING SCORES
• Acute hospital setting

• All patients above 16 yrs of age –

initial assessment

• Outpatients / and day care patients

who comes for invasive procedures or
those who receive anesthesia.
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NEWS SCORING SYSTEM

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Bedside NEWS

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 CASE STUDY – 1
• Mr. A is a 75 year old man , found
lying on the street by police. On
assessment his BP is 100/75 mm Hg ,
Pulse rate is 110 beats / mts,
respiration is 9 breaths/ mts
temperature is 38.3o C and SPO2 is
98%. Classify the patient??

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• Respiration – 1 • Systolic BP -1
• Oxygen saturation – 0 • Heart rate - 1
• Supplemental oxygen – 0 • Level of consciousness – 3
• Temperature - 1 • TOTAL = 7 - RED

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 CASE STUDY – 2
• Mr. B, 34 year old was admitted to EMD after
he was found unconscious in his apartment by
his wife .On examination
• Respiratory rate was 26 breaths/mt
• Heart rate – 102 beats/mt
• SPO2- 94% @2 l O2
• Temperature- 36.8o C
• BP- 120/80 mm Hg- classify ???

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• Respiration – 3 • Systolic BP -0
• Oxygen saturation – 1 • Heart rate - 1
• Supplemental oxygen –2 • Level of consciousness
• Temperature - 0 –3
• TOTAL = 10- RED

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 CASE STUDY 3
• Mrs. C, a 45 year old women
presented to OPD with complaints of
head ache. On examination
• Respiratory rate – 16 breaths/mt
• Heart rate – 78 beats/mt
• BP- 220/180 mm Hg
• SPO2- 98 % @ room air
• Temperature 37.2o C
• Classify the patient ?
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• Respiration – 0
• Oxygen saturation – 0
• Supplemental oxygen – 0
• Temperature - 0
• Systolic BP -3
• Heart rate - 0
• Level of consciousness – 0
• TOTAL = 3 - MEDIUM
SCORE
• EXTREME VARIATION
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08123317226
alihaedar.fk@ub.ac.id

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