GUIDELINE FOR THE USE OF THE MODIFIED

EARLY WARNING SCORE (MEWS)

ONEL Guideline Ref 039

Page 1 of 13
Issue date June 2011
Review date June 2014
Policy Reference: ONEL Guideline Ref 039

Policy Title: Guideline for the use of the Modified Early Warning Score
(MEWS)

Review Date: June 2014

Approval: Governance and Standards Committee

Author(s)/Further Geraldine Devaney, Productive Ward Lead,

Information:
Inpatient Services
Within ONELCS inpatient units the Early Warning Score and
Summary:
The Modified Early Warning Score (MEWS) are the two track
and trigger scoring systems in use. The triggers are based on
routine observations and are sensitive enough to detect subtle
changes in a patient’s physiology which will be reflected in a
change of score should the patient be improving or
deteriorating.
Implementation: This guideline will be disseminated to staff via the Trust’s
internet in read only files.

Impact: This is a mandatory risk management policy for the NHSLA

Risk Management Standards accreditation.

Version Control Summary

Version Date Status Comment Changes

1 June 2011 Ratified

ONEL Guideline Ref 039

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Issue date June 2011
Review date June 2014
CONTENTS

1 Guideline Statement and Guiding Principles 4

2 What are track and trigger warning systems? 4
3 Why do we need Track and Trigger systems? 5
4 When to use Track and Trigger systems 5
5 Mews Training 6
6 Monitoring and Audit 7
7 Associated Policies 7
8 References 7
Appendix A St Georges Inpatient Units 8
Appendix B Heronwood and Galleon Unit 12

ONEL Guideline Ref 039

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Issue date June 2011
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1. Guideline Statement and Guiding Principles

Outer North East London Community Services (ONELCS) Policies and

Guidelines are produced in conjunction with the following vision, which
underpins the development of the organisation.

• People are at the centre of what we are doing

• We can demonstrate a truly corporate spirit and collective responsibility
• We are clinically driven with managerial support
• We take responsibility for identifying and responding to need
• We seek to be fair and equal to all
• We seek to achieve our goals in partnership with others

2. What are track and trigger warning systems?

Within ONELCS inpatient units the Early Warning Score and The Modified
Early Warning Score (MEWS) are the two track and trigger scoring systems in
use. The triggers are based on routine observations and are sensitive enough
to detect subtle changes in a patient’s physiology which will be reflected in a
change of score should the patient be improving or deteriorating.

All patients have their vital signs measured and these are converted into a
colour coded risk band which documented on the front of the observation
chart. The nearer to the red risk band the more abnormal the vital signs
are. If the measurements reach above a certain threshold a doctor must be
called to assess the patient. The system allows for the regular monitoring and
recording of blood pressure, pulse, temperature, Glasgow Coma Score (GCS),
AVPU, urine output and respiratory rate.

Early warning scoring systems were originally developed with two specific
aims: to facilitate timely recognition of the patients with established or
impending critical illness; and to empower nurses and junior medical staff to
secure experienced help through the operation of a trigger threshold which, if
required, require mandatory attendance by a more senior member of staff.

Use of a Modified Early Warning Scoring system can also:

• Improve the quality of patient observation and monitoring

• Improve communication within the multidisciplinary team
• Allow for timely admission to intensive care
• Support good medical judgement
• Aid in securing appropriate assistance for sick patients
• Give a good indication of physiological trends
• Are a sensitive indicator of abnormal physiology

ONEL Guideline Ref 039

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Issue date June 2011
Review date June 2014
 However, MEWS is not:

• A predictor or outcome
• A comprehensive clinical assessment tool
• A replacement for clinical judgement

3. Why do we need Track and Trigger systems?

Confidential inquiry into quality of care before admission to intensive care

(McQuillan et al 1988) looked at why patients admitted from a ward area were
much less likely to survive intensive care than those from A&E and theatres.

The study found that:

• 41% of admissions to intensive care may have been avoidable if earlier

intervention had occurred
• 69% of admissions to intensive care occurred late in the development if
critical illness
• 54% of admissions had sub-optimal care prior to admission

The study highlighted the role of an early warning scoring system in the early
recognition and management of high risk patients.

A similar study by Stenhouse C. et al (2000) reviewed the use off an Early

Warning Score over a 9 month period. The introduction of the system
appeared to lead to earlier (and more appropriate) referral to intensive care.

Both the Royal College of Surgeons and the Association of Anaesthetists of

Great Britain and Ireland support the use of a MEWS system. The use of
MEWS was also a significant recommendation of a recent National
Confidential Enquiry into Patient Outcome and Death (NCEPOD 2005) study
and report.

4. When do we use Track and Trigger systems?

Track and trigger systems rely on the routine recording and charting of the
physiological status of the patient. These are simple observations that can be
performed by a nurse, doctor or other trained staff. These observations
include:-

• Pulse
• Respiratory Rate
• Temperature
• Urine Output
• Blood Pressure
• SPO2
ONEL Guideline Ref 039
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Review date June 2014
 Not all patients will require every part of the observation chart to be
completed. Patients on admission to the ward will have their observations
carried out and a MEWS score charted. The frequency and specifications of
all observations should be prescribed in the nursing care plan.

The following patients are considered to be at high risk of developing a critical

illness therefore it would be considered good practice to commence the track
trigger system at the earliest opportunity. This includes:

• All emergency admissions

• Unstable patients
• Patients whose condition is causing concern
• Patients requiring frequent or increasing frequency of observations
• Patients who have stepped down from a higher level of care
• Patients with chronic health problem
• Patients who are failing to progress

It may be necessary to assess a patient using the track and trigger system
score prior to transferring them to another ward within the hospital or to an
exterbal healthcare provider. If your patient is triggering the system consider
any other factors you need to deal with prior to transfer.

There are also patients in whom the use of a track and trigger system may be
inappropriate.

This includes:

• Patients who are terminally ill

This is not an exhaustive list. Although the majority of patients may benefit
from utilisation of track and trigger system the clinician’s own clinical
judgement dictates whether he or she requires the patient to be regularly
scored.

Where the wards responsible doctors’ decision is that a track and trigger score
is not appropriate, and then this should be clearly written onto the front of the
observation chart. An annotation should also be made in the patient notes
recording why the decision was made.

5. MEWS Training

• Medical staff receive information, instruction and training on the track and
triggers system during their core curriculum training. Use of the individual
units track and trigger forms will be discussed on induction.

ONEL Guideline Ref 039

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 • Nursing staff will receive information, instruction and training on the track
and trigger system as part of local induction and as part of local
ward/department training.
• Necessary, information on the use of Track and Trigger (and related
incidents) will be highlighted to medical staff and raised at Senior Nurse
meetings and Directorate Clinical Governance Committee meetings

6. Monitoring and Audit

• An audit of implementation of track and trigger will be undertaken annually.

• Results of the audit will go to the Governance and Standards Committee.
• The Inpatient Services Department will review this guideline every 3 years
unless a specific reason for an earlier review.
• Additional monitoring requirements can be found in the monitoring section
of the Resuscitation Policy TP032

7. Associated Policies

Resuscitation Policy TP032

8. References

NCEPOD. 2005. An Acute problem?

Stenhouse. C. Coates S., Tivey M., Allsop P., Parker T. (2000) Prospective
evaluation of a modified Early Warning Score to aid earlier detection of
patients developing critical illness on a general surgical ward. Br J.
Anaesthesia. 20003: 84: 663P.

McQuillan, Pilkington, Taylor, Short, Morgan, Nielsen, Barrett and Smith.

(1998). Confidential inquiry into quality of care before admission to intensive
care, BMJ, 1998, 316 (7148) 1853-1858.

Sabbe C., Davies R., Williams E., Rutherford P., Gemmell L. (2003) Effect of
introducing the modified Early Warning score on clinical outcomes, cardio-
intensive care utilisation in acute medical admissions. Anaesthesia, 2003 58
(8) 797-802.

Williams W. eta l (2003) Outreach critical care-cash for no questions? British

Journal of Anaesthesia, 2003 90 (5) 699-702.

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 Appendix A
St Georges Inpatient Units

1. Observation Chart

ONEL CS has implemented a standard MEWS system for use across all directorates
and specialities.

MEWS is incorporated within the Standard Observation Chart.

2. MEWS Score

Table 1

MEWS Score 3 2 1 0 1 2 3
Temp (core) <35.0 35.1-36.0 36.1-38.0 38.1-38.5 >38.6
Pulse/Apex <40 41-50 51-100 101-110 111-130 > 131
Systolic <70 71-80 81 - 100 101 - 199 >200
Blood
Pressure
Respiratory <8 9-14 15-20 21-29 >30
rate
SPO2 <85 85-89 90-93 >94
CNS New Alert Voice Pain Unrespon
response confusion -sive
(AVPU) /agitation
Urine output <500ml/ <750ml/2 1000-750
24hours 4 hours ml/
24hours

AVPU is a simple assessment where A = Alert

V = Responds to verbal commands only
P = Responds to pain
U = completely unresponsive

.
3. Triggers Scores

A MEWS Score of 2 in ANY category indicates the need for close and frequent
observation of the patient.

A MEWS score of 4 and/or an increase of 2 or more indicates that the patient is

potentially unwell and means that urgent medical attention is required.

4. How to respond to MEWS

ONEL Guideline Ref 039

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A MEWS Score must be calculated where a patient scores 2 or more in ANY
observation category.

At the initial stage MEWS observations should be calculated and recorded at ½

hourly intervals (this may be changed to less frequent intervals after formal
medical review of the patient).

A MEWS of 4 or more and/or a MEWS Score increase of 2 or MUST trigger an

urgent referral for medical review.

During daytime hours, nursing staff should initiate a MEWS Call to the relevant
ward Doctor. Out of hours this should be to the on call Doctor.

If there is no response to the initial MEWS call within 10 minutes, nursing staff
should re bleep the ward responsible Doctor and if there is still no response after
a further 10 minutes, nursing staff should initiate a fast-bleep to the on call
Register and on call Senior Nurse/Bleep holder.

A member of medical staff MUST attend and assess the patient within 30
minutes, unless there are exceptional circumstances preventing a review by
medical staff.

NB: A failure to attend a MEWS call within an acceptable timescale (<30 mins)
should result in the completion of a clinical incident form.

A MEWS action plan must be agreed and documented for any patient reviewed.

When there is no improvement with the patient within 1 hour, this must initiate
immediate senior review and, if necessary emergency transfer to Relevant
Accident and Emergency.

5. Out of hours reporting

Out of hours a MEWS score of 4 or more and/or MEWS score increase of 2 or

more MUST result in a Call to the on call Doctor and Senior Nurse/Bleep holder,
who will also ensure that discussion on the management of a MEWS Trigger
patient is formally discussed at the next handover.

6. Recording MEWS

Observations and MEWS Scores MUST be recorded on the standard Observation

Chart.

The decision to initiate a MEWS call must be recorded in the patient’s notes. A
standard MEWS Event Sticker (see Table 2) should be used for this purpose.

ONEL Guideline Ref 039

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Review date June 2014
Table 2: MEWS Event Sticker

MEWS EVENT
WARD:
DATE:
TIME:
MEWS SCORE:
NAME & GRADE OF
1ST RESPONDER:
TIME SEEN:
OUTCOME:
If no response from 1st responder within 30 minutes, call
ON-Site SHO/Registrar

All notations in the patient’s notes (including inclusion of the MEWS

Event Sticker) must be: - Legible
- Signed
- Dated
- Timed
- In Black ink

ONEL Guideline Ref 039

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 ST GEORGES MEWS FLOWCHART

Calculate MEWS Score

1-3 4+ MEWS Score

Increases by 2

Inform SHO/ on call Senior Nurse/Bleep holder

Inform
ww HO/SHO
wwllllllllll
wwwwww
(C
Observe,
repeat at
appropriate Document all relevant details in medical
ww
intervals notes (MEWS sticker in notes)

Record
Bleep Ward SHO after 10 Minutes

Fastbleep via Switchboard if no response

from medical team in 10 minutes
If no
response
within 30
minutes
Medical Officer attends within contact /call
30 mins Senior
Nurse/Bleep
holder
MEWS action plan identified

If no improvement by patient
within 1 hour

Senior Review

Registrar Review ONEL Guideline Ref 039

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Emergency Transfer
 APPENDIX B – HERONWOOD AND GALLEON MEWS POLICY

EARLY WARNING SYSTEM

Risk Band Urgent Warning Observe - At risk Normal Observe - At Warning Urgent
Range risk

Temp (core) <35.0 <36.0 36.0 - 37.5 >38.0 >39.0

Pulse <45 45-49 50-59 60-89 90-114 115-129 ≥130

Systolic Blood <80 80-89 90-99 100 - 159 160-179 180-199 ≥200
Pressure or or
>40 mmHg drop from >20drop from
normal normal

Respiratory rate <8 <10 10 - 19 20-24 25-30 >30

Sp02 <85 85-89 90-93 ≥94

CNS response New confusion Alert Voice Pain Unresponsive

(AVPU)

GCS ≤10 11-12 13-14 15

Urine output <0.5 ml/kg/hr <0.5 ml/kg/hr for 0.5 - 3 >3 ml/kg/hr
(catheterised) for 2 hours 1 hour ml/kg/hr

Urine Output <500 <750 1000-750 ml/24

ml/24 ml/24 hours hours
hours

Normal » Regular Observations

» Maintain frequent observations [2-4 hours] of ’high risk’ patients

Observe - at » Inform nurse-in-charge immediately

» Implement first line treatment
risk » Increase frequency of observations to 1 hourly (TPR, BP, Sp02)
» Repeat medical / senior nurse review within 4 hours - if no improvement seek SENIOR advice or
sooner if not improving, i.e. GP or PELC
» Continue 2 hourly observations until return to normal AND nurse-in-charge review

Warning » Inform nurse-in-charge immediately

» Implement first line treatment
» Commence monitoring (BP, Sp02)
» Increase frequency of observations to 1 hourly until initial medical review
» Continue 1 hourly observations until condition stabalised
» Repeat medical / senior nurse review within 2 hours - if no improvement seek SENIOR advice or
sooner if not improving, i.e. GP or PELC
» Maintain 2 hourly observations until return to normal AND nurse-in-charge review

Urgent » Inform nurse-in-charge immediately

» Implement first line treatment
» Commence monitoring (BP, Sp02, pulse, ECG)
» Commence 1/4 hourly until initial medical review
» Continue 1/2 hourly observations until condition stabalised
» Medical review within 1 hours - if no improvement seek SENIOR advice or sooner if not
mproving, i.e. GP or PELC
» Maintain 1 hourly observations until return to normal AND nurse-in-charge review
» Transfer to A&E if no improvement

ONEL Guideline Ref 039

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Review date June 2014
 Heronwood and Galleon MEWS Flowchart

Calculate MEWS Score

Observe At Warning Urgent

Risk

Inform Nurse immediately

Implement first line treatment

Increase frequency of observation to 1 hourly

Document all relevant details in medical notes

Repeat medical review/senior nurse review within 4

hours –if no improvement seek SENIOR advice or
sooner if not improving, i.e. GP or PELC

Continue 2 hourly observations until return to normal

AND nurse- in –charge review

Transfer to A&E if no improvement

ONEL Guideline Ref 039

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