National Early Warning Score Adult Patient Observation Chart - Health Service Executive

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Patient Name:
Date of Birth:
Hospital Name:
Healthcare Record No:
Addressograph
Document Number during this Admission
NATIONAL EARLY WARNING SCORE
ADULT PATIENT OBSERVATION CHART
Escalation Protocol Flow Chart
Minimum
Total Score
ALERT
RESPONSE
Observation
Frequency
1
12 Hourly
Nurse in charge
Nurse in charge to review if new score1
2
6 Hourly
Nurse in charge
Nurse in charge to review
Nurse in charge &
3
4 Hourly
1. SHO to review within 1 hour
Team/On-call SHO
1. SHO to review within
hour
2. Screen for Sepsis
3.
If no response to treatment within 1 hour
Nurse in charge &
4-6
contact Registrar
1 Hourly
Team/On-call SHO
4. Consider continuous patient monitoring
5. Consider transfer to higher level of care
1. Registrar to review immediately
Nurse in charge &
2. Continuous patient monitoring recommended
Team/On-Call Registrar
7
Hourly
3. Plan to transfer to higher level of care
Inform Team/On-Call
4. Activate Emergency Response System (ERS)
Consultant
(as appropriate to hospital model)
Note: Single Score triggers
Score of 2
Nurse in charge &
Hourly
1. SHO to review immediately
HR ≤ 40
Team/On-call SHO
(Bradycardia)
1. SHO to review immediately
*Score of 3
Hourly or as
2. If no response to treatment or still concerned
Nurse in charge &
in any single
indicated by
contact Registrar
Team/On-call SHO
parameter
patient’s condition
3. Consider activating ERS
*In certain circumstances a score of 3 in a single parameter may not require ½ hourly observations i.e. some patients on O
.
2
• When communicating patients score inform relevant personnel if patient is charted for supplemental oxygen e.g. post-op.
• Document all communication and management plans at each escalation point in medical and nursing notes.
• Escalation protocol may be stepped down as appropriate and documented in management plan.
IMPORTANT:
1. If response is not carried out as above CNM/Nurse in charge must contact the Registrar or Consultant.
2. If you are concerned about a patient escalate care regardless of score.
National Early Warning Score (NEWS) Key
3
2
1
0
1
2
3
SCORE
Respiratory Rate (bpm)
8
9 - 11
12 - 20
21 - 24
25
SpO
(%)
91
92 - 93
94 - 95
96
2
Inspired O
A
ir
Any
O
(F
O
)
i
2
2
2
Systolic BP (mmHg)
≤ 90
91 - 100
101 - 110
111 - 249
≥ 250
Heart Rate (BPM)
≤ 40
41 - 50
51 - 90
91 - 110
111 - 130
131
Voice (V), Pain (P),
AVPU/CNS Response
Alert (A)
Unresponsive (U)
Temp (°C)
35.0
35.1 - 36.0
36.1 - 38.0
38.1 - 39.0
≥ 39.1
Note: Where systolic blood pressure is ≥ 200mmHg, request Doctor to review.

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