1. Early Warning Scores in the ED
James Griffiths
Consultant EM
Barnsley
CEM FOAMed Network
@YorksHumberFoam

2. Objectives Evolution of Early Warning Scores
Rapid Emergency Medicine Score (REMS)
National Early Warning Score (NEWS)
EWS in the ED
Future work?
Conclusion

3. Background

4. 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

5. M(odified)EWS Surgical patients Potential benefit from critical care
Deviation from normal BP
Urine output
Potential benefit from critical care
Stenhouse et al. Br J Anaesth 2000;84:663

6. Patients at risk Score 3 2 1 SBP <70 71-80 81-100 101-199 ≥200 HR
SBP
<70
71-80
81-100
≥200 HR
<40
41-50
51-100
≥130 RR
<9
9-14
15-20
21-29
≥30
Temp
<35
≥38.5
AVPU
Alert
Voice
Pain
Un-responsive
Subbe et al. Q J Med 2001;94:

7. REMS 1 2 3 4 5 6 Age <45 45-54 55-64 65-74 >74 HR 70-109 55-691 2 3 4 5 6
Age
<45
45-54
55-64
65-74
>74 HR
70-109
55-69
40-54
<40
>179 RR
12-24
10-11
25-34
6-9
35-49
>49
SBP
90-129
70-89
<69
GCS
>13
11-13
8-10
5-7
<5 O2
>89
86-89
75-85
<75
Olsson & Lind. Acad Emerg Med 2003;10:

8. 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)

9. 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

10. NEWS Royal College of Physicians working party July 2012
Based on a large number of vital signs from an electronic patient database

11. Prytherch et al. Resuscitation 2010. 81:932-937

15. Smith et al. Resuscitation 2013. 84:465-470

16. The Future?

17. Finally...
Smith et al. Resuscitation :