Vital sign | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
---|---|---|---|---|---|---|---|
Respiratory rate, min− 1 | < 9 | 9–11 | 12–20 | 21–24 | > 24 | ||
Arterial oxygen saturation, % | < 92 | 92–93 | 94–95 | > 95 | |||
Oxygen supplement L x min− 1 | Yes | No | |||||
Pulse rate, min−1 | < 41 | 41–50 | 51–90 | 91–110 | 111–130 | > 130 | |
Systolic blood pressure mmHg | < 91 | 91–100 | 101–110 | 111–219 | > 219 | ||
Mental status, AVPU¶ | A | V, P, U | |||||
Temperature, °C | < 35.1 | 35.1–36.0 | 36.1–38.0 | 38.1–39.0 | > 39.0 | ||
EWS algorithm | |||||||
NEWS | Frequency of monitoring | Clinical response according to escalation protocol | |||||
0–1 | Minimum 12 hourly ± 1 h | Continue EWS monitoring minimum 12 hourly Frequency can be increased | |||||
2 | Minimum 6 hourly ± 30 min | Nursing staff ABCDE optimise | |||||
3–5 | Minimum 4 hourly | Nursing staff ABCDE optimise AND informs the on-call physician The on-call physician makes a documented treatment plan | |||||
6 | Minimum 4 hourly | Nursing staff ABCDE optimise AND contacts the on-call physician immediately The on-call physician assesses AND makes a documented treatment plan | |||||
7–8 | Minimum 1 hourly | Nursing staff ABCDE optimise AND contacts the on-call physician immediately – attends within 30 min The on-call physician assesses AND makes a documented treatment plan immediately Consider contacting the MET» or anaesthesiologic assistance | |||||
> 9 | Minimum 0.5 hourly | Nursing staff ABCDE optimise AND contacts the on-call physician immediately – attends within 15 min The on-call physician assesses AND makes a documented treatment plan immediately Consider contacting the MET» or anaesthesiologic assistance |