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Table 2 EWS thresholds and clinical responses to triggers used in the Capital Region of Denmark

From: Barriers and facilitating factors related to use of early warning score among acute care nurses: a qualitative study

EWS

Frequency of monitoring

Clinical response according to escalation protocol

0–1

Minimum 12 hourly

• Continue monitoring minimum 12 hourly

2

Minimum 6 hourly

• Assessment of airway, breathing and circulation and appropriate intervention

3–5

Minimum 4 hourly

• Assessment of airway, breathing and circulation and appropriate intervention

• Nurse in charge informs on-call physician, who assesses patient and plans appropriate treatment and/ or diagnostics

6

Minimum 4 hourly

• Assessments of airway, breathing and circulation and intervenes appropriately

• Urgent assessment by on-call physician, including plan for appropriate treatment and diagnostics

7–8

Minimum 1 hourly

• Assessment of airway, breathing and circulation and appropriate intervention

• Emergency assessment (within 30 min) by on-call physician, including plan for appropriate treatment and diagnostics

• Consider call to medical emergency team (MET)

≥ 9

Minimum ½ hourly

• Assessment of airway, breathing and circulation and appropriate intervention

• Emergency assessment (within 15 min) by on-call physician, including plan for appropriate treatment and diagnostics

• Patient must be evaluated with senior physician or MET