James Griffiths

Consultant EM
Barnsley
CEM FOAMed Network

@YorksHumberFoam
Objectives
 Evolution of Early Warning Scores
 Rapid Emergency Medicine Score (REMS)
 National Early Warning Score (NEWS)
 EWS in the ED
 Future work?
 Conclusion
First EWS
Developed in 1997 by
Morgan et al
Based on five
physiological
parameters:
SBP
Pulse
Resp rate
Temp
AVPU

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

M(odified)EWS
Surgical patients
Deviation from normal
BP
Urine output
Potential benefit from
critical care

Stenhouse et al. Br J Anaesth 2000;84:663

Patients at risk
Score 3 2 1 0 1 2 3
SBP <70 71-80 81-100 101-199 ≥200

HR <40 41-50 51-100 101-110 111-129 ≥130

RR <9 9-14 15-20 21-29 ≥30

Temp <35 35-38.4 ≥38.5

AVPU Alert Voice Pain Un-

respo
nsive

Subbe et al. Q J Med 2001;94:521-526

REMS
0 1 2 3 4 5 6

Age <45 45-54 55-64 65-74 >74

HR 70-109 55-69 40-54 <40

110-139 140-179 >179
RR 12-24 10-11 6-9 35-49 >49
25-34
SBP 90-129 70-89 150-179 <69
130-149 >179
GCS >13 11-13 8-10 5-7 <5

O2 >89 86-89 75-85 <75

Olsson & Lind. Acad Emerg Med 2003;10:1040-1048

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

NICE Clinical Guideline 50 (2007)

DoH Clinical Indicators
The new Department of Health Quality Indicators
that will replace the four-hour standard record a time
to full initial assessment of patients attending EDs
which includes a pain score and early warning score
in patients arriving by 999 ambulance

Department of Health 2011

NEWS
Royal College of
Physicians working
party July 2012
Based on a large number
of vital signs from an
electronic patient
database
Prytherch et al. Resuscitation 2010. 81:932-937
Smith et al. Resuscitation 2013. 84:465-470
The Future?
Smith et al. Resuscitation 2013. 84:465-470