1. Early Warning Score & Vital Sign Chart(s)
Proposed content for E-Learning

2. CCDHB Early Warning Score (EWS)
Welcome to the EWS and vital sign chart e-learning site. This resource provides an opportunity to learn about the use of the new adult EWS system, paediatric EWS (PEWS) and maternity (MEOWS). The online training will help you learn how to use the EWS and vital sign chart and operate the escalation pathway. Please note that the adult EWS is designed for use in adults aged 16 years and above. If you work in paediatrics please refer to the PEWS training, and for pregnancy & obstetrics please use the MEOWS training.
ADULT EWS
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PEWS
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MEOWS
Begin E-Learning
Click on blue “Begin E-Learning” box to be taken to logon page (DHB user ID and password) and then to training session
Links
EWS matrix
Wellington chart
Kenepuru chart
CNE’s teaching package
EWS & vital sign policy
Links
PEWS matrices
PEWS age-specific charts
PEWS escalation pathway
EWS & vital sign policy
Links
MEOWS matrix
MEOWS chart
MEOWS escalation pathway

3. Training Session: PAEDIATRIC
Learning objectives
PEWS parameters
Calculating a PEWS & recording vital signs
Triggering a PEWS response & escalation
PEWS Quiz

4. Learning Objectives
After completion of this e-learning session you will be able to:
Understand the benefits of the PEWS
Describe the seven PEWS parameters
Calculate an PEWS correctly
Use the mandatory PEWS triggers to initiate a mandated response
Understand how the PEWS escalation pathway works
Know how the PEWS Modification Box is used

5. 1. Benefits of EWS
Early Warning Scores (EWS) have been developed internationally, to help identify acutely ill and deteriorating patients in acute care hospitals
EWS focus on EARLY recognition of clinical signs of deterioration. EWS trigger a fast and efficient clinical response, which helps prevent deterioration to cardiac arrest. This EARLY approach to acute deterioration optimises patient outcomes.

6. Paediatric EWS (PEWS)
In recent years Paediatric EWS have been developed internationally, with Toronto and Queensland publishing validated PEWS systems these have been implemented in a number of centres around NZ ( Starship, Kidz First and CHCH DHB1-4)
The PEWS system (January 2014) is based on the Queensland CEWT system Adopted by CHCH DHB and used with kind permission. There is a move towards a standardised EWS across the sub-regional 3 DHBs (Hutt Valley, Wairarapa & CCDHB)

7. References
Tibballs J, Kinney S, Duke T, Oakley E, Hennessy M. Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results. Archives of disease in childhood 2005;90(11):
Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. Journal of critical care 2006;21(3):271-8.
Haines C, Perrott M, Weir P. Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool. Intensive Crit Care Nurs 2006;22(2):73-81.
Monaghan A. Detecting and managing deterioration in children. Paediatric nursing 2005;17(1):32-5.

8. 2. PEWS Parameters
There are 7 parameters that form the basis for the EWS:
Respiratory rate
Oxygen saturation
Supplemental oxygen
Respiratory distress
Systolic blood pressure
Heart rate
Level of consciousness

9. PEWS charts There are 5 age-specific PEWS vital sign charts:
0-3 months
4-11months
1-4 years
5-11 years
12 + years
For the purposes of this training, the 4-11month chart is used for all clinical examples
Link to chart
Link to chart
Link to chart
Link to chart
Link to chart

10. Respiratory Rate (4-11mth)
The PEWS triggers are sensitive to deterioration. PET call criteria are triggered at <10 or >60 per minute

11. Measuring Respiratory Rate
An elevated respiratory rate is one of the most sensitive indicators of acute illness in paediatric patients.
To calculate an accurate respiratory rate, the patient’s breathing must be assessed for a full minute.

12. Respiratory Distress
The degree of effort (work of breathing) allows clinical assessment of the severity of respiratory disease.

13. Measuring Respiratory Distress
Along with respiratory rate you are looking at the following:
Recession
Inspiratory or expiratory noises
Grunting
Accessory muscle use
Flaring nostrils
Gasping
Efficacy of breathing e.g. decreased air entry, chest expansion

14. Supplemental Oxygen
The scoring system allows you to use either FiO₂ or O₂ L/min, as part of the EWS. Talk to Charlotte
Regularly review your patient’s need for oxygen and if they don’t need it, remove it
All oxygen administration MUST be prescribed by a doctor, and regularly reviewed. Advanced Oxygen Therapy i.e BCPAP and Hi Flow Oxygen must be prescribed on the blue Advanced Oxygen prescription either prior to or at commencement of therapy.

15. Oxygen Saturation
For patients receiving supplemental O₂, SpO₂ targets must be documented in the patient’s clinical record, or medication chart

16. Measuring Oxygen Saturations
Measurement of SpO₂ by pulse oximetry is now a standard practice in acute care settings.
Decreased oxygen saturations can be an indicator of impaired pulmonary and cardiac function.
When using a pulse oximeter, make sure that the nail/skin interface is clean from anything that might impair the trace e.g. nail polish

17. Systolic Blood Pressure
Normal Blood Pressure varies with age.
Use of the correct cuff size is crucial if an accurate blood pressure measurement is to be obtained. (width should cover 2/3 of the length of the upper arm, inside of cuff (bladder) no more than 1/3 of arms circumference)

18. Measuring Blood Pressure
Blood pressure is to be recorded as per existing standards; on admission, preoperatively and on return to ward postoperatively.
In neonates and infants, blood pressure should be recorded if renal disease or co-arctation of aorta are suspected or if there are signs of hypotension.
Any child or adolescent should also have their blood pressure measured with symptoms of hypotension, hypertension, renal or cardiac disease, diabetes or adrenal disorder, head injury or trauma.
Blood pressure should be recorded 4-8 hourly or more frequently if indicated. Use correct cuff size.
Blood pressure must be recorded if the PEWS score is 3 or greater based on other parameters.

19. Heart Rate
Tachycardia is triggered at 160 per minute and bradycardia at PET call criteria is a heart rate ≤60 per minute

20. Measuring Heart Rate
Heart rate is an important indicator of any acute condition
The normal heart rate varies with age and activity
Tachycardia may be due to a number of causes:
Fever
Anaemia
Shock
Dysrhythmia
Sepsis
Metabolic disturbances especially due to dehydration
Pain/nausea/distress
Medications
Bradycardia is often a sign of an impending cardiorespirtaory arrest. Other causes of bradycardiac may be an indicator of hypothermia, CNS depression, heart block or hypothyroidism.
When assessing the heart rate it is best practice to manually feel for the pulse, rather than rely on pulse oximetry. Palpation will provide important clinical information e.g. skin temperature, regularity and strength of pulse

21. Level of Consciousness
A decreased level of consciousness is an indicator of CNS depression and narcosis
The AVPU assessment is a quick and accurate tool to measure and record a patient’s level of consciousness:
A – alert or awake
V – responds to voice
P – responds to pain stimulus
U - unresponsive

22. 3. Using PEWS
The minimum frequency for taking a full set of vital signs & calculating the Early Warning Score is every 4 hours (Adult & paediatric vital sign measurement, EWS and escalation policy. Document ID
The frequency for taking vital signs may be increased or decreased, according to the clinical need of each patient.
Each EWS parameter is weighted, so that the greater the deviation from normal, the higher the EWS score. The weighted scores range from 0 (normal) to 3 (grossly abnormal).
The individual parameter scores are then added together to derive an aggregated EWS. If significant, a clinical response is triggered

23. The vital sign charts have colour-coding to help identify each EWS zone:
White = normal
Yellow = potential to deteriorate
Orange = indicates acute illness or unstable chronic disease
Red = likely to deteriorate rapidly
Blue = immediately life threatening critical illness
The PEWS system also allows for single parameter scoring e.g. if any vital sign falls in a coloured zone, the associated action is triggered.

24. PEWS Process 1. Measure & document a full set of vital signs
2. Calculate & document the PEWS
3. Use the PEWS to identify the appropriate level of escalation
4. Consider most appropriate clinical setting for ongoing care

25. Level of Consciousness
4. PEWS Matrix (4-11mth)
SCORE
PET 3 2 1
ZONE
BLUE
RED
ORANGE
YELLOW
WHITE
Resp Rate
<10
10-15
15-20
20-45
45-50
50-55
55-60
>60
SpO₂
≤85
85-88
89-92
93-100
Supplemental O₂
0-2L
21-30%
2-10L
30-39%
11-14L
40-50%
≥15 L
>50%
Respiratory Distress
nil
mild
moderate
severe
Sys BP
<50
55-65
65-75
75-120
>120
Heart Rate
<60
60-80
80-90
90-100
>190
Level of Consciousness
Alert
Voice
Pain
Unresponsive or fitting

26. Wellington Hospital’s vital sign chart

27. 5. Escalation Pathway
The PEWS escalation pathway is MANDATORY and has been endorsed for use by clinical directors and managers. Any deviations away from this pathway must be documented in the patient’s clinical record

28. PEWS 1-3 (4-11mth)
TBC with clinical leaders

29. PEWS 4-5 (4-11mth)
TBC

30. PEWS 6-7 (4-11mth)
TBC

31. PEWS 8+ (4-11mth)
The colour associated with paediatric emergency team calls (PET) is BLUE
TBC

32. The PEWS system does not replace sound clinical judgment
If you are seriously concerned about any patient, regardless of vital signs/PEWS, call ‘777 PET’
Alternatively, if there is no timely response to your request for review, escalate to the next coloured zone.

33. 6. Modification to PEWS Triggers
There are cases when clinically stable patients may have abnormal vital signs. In order to accommodate this and prevent alarm-fatigue from over-triggering patient reviews, the PEWS can be modified
Any modification to the PEWS must be made by a Consultant or Registrar and be regularly reviewed by the primary team
Modification to PEWS must never be used to normalise abnormal vital signs in clinically unstable patients, or deter ward staff from accessing the help they need e.g. preventing 777 calls from being made

34. CCDHB PEWS Modification Box
TBC

35. Paediatric EWS Quiz

36. True or False?
PEWS focus on early recognition of clinical signs and help identify deteriorating patients 
PEWS have been shown to decrease numbers of in-hospital cardiac arrest & respiratory arrest 
CCDHB’s PEWS is based on a validated PEWS system which has been demonstrated to be superior to all others at predicting mortality 
 for True,  for False

37. What are the 7 PEWS parameters?
Respiratory distress 
Heart rate 
Level of consciousness 
Urine output 
Oxygen saturation 
Systolic blood pressure 
Supplemental oxygen 
Diastolic blood pressure 
Respiratory rate 
 for True,  for False. On quiz, blank answer boxes are provided which when clicked are automatically occupied with a tick. Double click to remove an answer. Press ‘Submit Answer’ once you think you have the correct EWS. The correct answer is then revealed.

38. Which of the vital signs is considered the most sensitive indicator of acute illness?
Temperature 
Heart rate 
Respiratory rate 
 for True,  for False

39. At CCDHB, what is the minimum frequency of vital signs to be taken on every patient?
Daily 
Once per shift 
6 hourly 
4 hourly 
 for True,  for False

40. Use the 4-11month PEWS Matrix (insert link to PEWS matrix) to calculate the PEWS:
Respiratory Rate 
Oxygen Saturation 91% 
Supplemental Oxygen 11L 
Respiratory Distress severe 
Systolic BP 
Heart Rate 
Conscious level Alert 
Click on circle and enter number 0-3

41. Escalation Response The correct PEWS is 9
Respiratory Rate 
Oxygen Saturation 91% 
Supplemental Oxygen 11L 
Respiratory Distress Severe 
Systolic BP 
Heart Rate 
Conscious level Alert 
Escalation Response = link to appropriate part of escalation pathway (blue zone= PET)
Escalation
Response
The correct
PEWS is 9

42. Use the 4-11month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS:
Respiratory Rate 
Oxygen Saturation 97% 
Supplemental Oxygen FiO2 33% 
Respiratory Distress mild 
Temperature 
Systolic BP 110/82 
Heart Rate 
Conscious level Alert 

43. Escalation Response The correct PEWS is 4
Respiratory Rate 
Oxygen Saturation 97% 
Supplemental Oxygen FiO2 33% 
Respiratory distress mild 
Temperature 
Systolic BP 110/ 
Heart Rate 
Conscious level Alert 
Escalation Response = link to appropriate part of escalation pathway (yellow zone)
Escalation
Response
The correct
PEWS is 4

44. Use the 4-11 month PEWS Matrix (insert link to EWS Matrix here) to calculate the PEWS:
Respiratory Rate 
Oxygen Saturation 92% 
Supplemental Oxygen 3L 
Respiratory distress mild 
Temperature 
Systolic BP 115/82 
Heart Rate 
Conscious level Voice 

45. Escalation Response The correct PEWS is 9
Respiratory Rate 
Oxygen Saturation 92% 
Supplemental Oxygen 3L 
Respiratory distress mild 
Temperature 
Systolic BP 115/82 
Heart Rate 
Conscious level Voice 
Escalation Response = link to appropriate part of escalation pathway (blue zone)
Escalation
Response
The correct
PEWS is 9

46. Place the PEWS processes in the correct order
Measure & document a full set of vital signs
Calculate & document the PEWS
Use the PEWS to identify the appropriate level of escalation
Consider most appropriate clinical setting for ongoing care
Drag and drop text boxes into the correct sequential order.
If logistically impossible, then have the 4 processes set out in a table format, with blank boxes next to them in which you can enter their order (1-4).

47. True or False?
The PEWS chart is used throughout adult wards at Kenepuru and Wellington campuses
There are 5 age-specific PEWS charts
The colour-codes used to help identify each PEWS zone are: yellow, orange, pink and blue
 

48. True or False?
The PEWS replaces sound clinical judgment The PEWS modification box must only be filled in by a Consultant or a Registrar Pink is the colour associated with triggering PET
 
Blue is the colour associated with PET