Transcript CCDHB Vital Sign Charts

Early Warning Score & Vital Sign
Chart(s)
Proposed content for E-Learning
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
Begin E-Learning
PEWS
Begin E-Learning
Links
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EWS matrix
Wellington chart
Kenepuru chart
CNE’s teaching package
EWS & vital sign policy
Links
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PEWS matrices
PEWS age-specific charts
PEWS escalation pathway
EWS & vital sign policy
MEOWS
Begin E-Learning
Links
 MEOWS matrix
 MEOWS chart
 MEOWS escalation
pathway
Training Session: PAEDIATRIC
o Learning objectives
o PEWS parameters
o Calculating a PEWS & recording vital signs
o Triggering a PEWS response & escalation
o PEWS Quiz
Learning Objectives
After completion of this e-learning session you will
be able to:
1. Understand the benefits of the PEWS
2. Describe the seven PEWS parameters
3. Calculate an PEWS correctly
4. Use the mandatory PEWS triggers to initiate a
mandated response
5. Understand how the PEWS escalation pathway
works
6. Know how the PEWS Modification Box is used
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.
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)
References
1. 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):1148-52.
2. 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.
3. 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.
4. Monaghan A. Detecting and managing deterioration in
children. Paediatric nursing 2005;17(1):32-5.
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
PEWS charts
There are 5 age-specific PEWS vital sign charts:
– 0-3 months
– 4-11months
– 1-4 years
– 5-11 years
– 12 + years
Link to chart
Link to chart
Link to chart
Link to chart
Link to chart
For the purposes of this training, the 4-11month
chart is used for all clinical examples
Respiratory Rate (4-11mth)
The PEWS triggers are sensitive to deterioration.
PET call criteria are triggered at <10 or >60 per
minute
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.
Respiratory Distress
The degree of effort (work of breathing) allows
clinical assessment of the severity of respiratory
disease.
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
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.
Oxygen Saturation
For patients receiving supplemental O₂, SpO₂
targets must be documented in the patient’s
clinical record, or medication chart
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
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)
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.
Heart Rate
Tachycardia is triggered at 160 per minute and
bradycardia at 100. PET call criteria is a heart
rate ≤60 per minute
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
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
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 1.101901.
• 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
The vital sign charts have colour-coding to help identify each EWS
zone:
o White = normal
o Yellow = potential to deteriorate
o Orange = indicates acute illness or unstable chronic disease
o Red = likely to deteriorate rapidly
o 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.
PEWS Process
1. Measure &
document a
full set of vital
signs
2. Calculate &
document the
PEWS
3. Use the
4. Consider
PEWS to
identify the
appropriate
level of
escalation
most
appropriate
clinical setting
for ongoing
care
4. PEWS Matrix (4-11mth)
SCORE
PET
3
2
1
0
1
2
3
PET
ZONE
BLUE
RED
ORANGE
YELLOW
WHITE
YELLOW
ORANGE
RED
BLUE
Resp Rate
<10
10-15
15-20
20-45
45-50
50-55
55-60
>60
≤85
85-88
SpO₂
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
50-55
55-65
65-75
75-120
Heart Rate
<60
60-80
80-90
90-100
100-160
160-170
Alert
Voice
Level of
Consciousness
25
89-92
>120
170-190
>190
Pain
Unresponsive
or fitting
Wellington Hospital’s vital sign chart
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
PEWS 1-3 (4-11mth)
PEWS 4-5 (4-11mth)
PEWS 6-7 (4-11mth)
PEWS 8+ (4-11mth)
The colour associated with paediatric
emergency team calls (PET) is BLUE
• 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.
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
CCDHB PEWS Modification Box
Paediatric EWS Quiz
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.

• 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









Which of the vital signs is considered the most
sensitive indicator of acute illness?
– Temperature
– Heart rate
– Respiratory rate



At CCDHB, what is the minimum frequency of
vital signs to be taken on every patient?
– Daily
– Once per shift
– 6 hourly
– 4 hourly




Use the 4-11month PEWS Matrix (insert link to
PEWS matrix) to calculate the PEWS:
– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Respiratory Distress
– Systolic BP
– Heart Rate
– Conscious level
58
91%
11L
severe
105
132
Alert







– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Respiratory Distress
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
58
91%
11L
Severe
105
132
Alert







The correct
PEWS is 9
Use the 4-11month PEWS Matrix (insert link to EWS
Matrix here) to calculate the PEWS:
–
–
–
–
–
–
–
–
Respiratory Rate
Oxygen Saturation
Supplemental Oxygen
Respiratory Distress
Temperature
Systolic BP
Heart Rate
Conscious level
51
97%
FiO2 33%
mild
37.5
110/82
145
Alert








– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Respiratory distress
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
51
97%
FiO2 33%
mild
37.5
110/82
145
Alert








The correct
PEWS is 4
Use the 4-11 month PEWS Matrix (insert link to
EWS Matrix here) to calculate the PEWS:
–
–
–
–
–
–
–
–
Respiratory Rate
Oxygen Saturation
Supplemental Oxygen
Respiratory distress
Temperature
Systolic BP
Heart Rate
Conscious level
51
92%
3L
mild
38.2
115/82
171
Voice








– Respiratory Rate
– Oxygen Saturation
– Supplemental Oxygen
– Respiratory distress
– Temperature
– Systolic BP
– Heart Rate
– Conscious level
Escalation
Response
51
92%
3L
mild
38.2
115/82
171
Voice








The correct
PEWS is 9
Place the PEWS processes in the
correct order
Consider most
appropriate
clinical setting
for ongoing
care
Calculate &
document the
PEWS
Use the PEWS
to identify the
appropriate
level of
escalation
Measure &
document a
full set of vital
signs
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

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
