Vital signs are measured, from which a score is calculated. Action is then triggered according to the score (Table 1).
EWSS aim to pick up problems earlier than isolated signs and are useful as repeated measurements to track progress over time. They are not prognostic indicators.
|
3 |
2 |
1 |
0 |
1 |
2 |
3 |
|
|
SBP (mm Hg) |
<70 |
71-80 |
81-100 |
101-199 |
|
≥200 |
|
|
Pulse rate (bpm) |
<40 |
41-50 |
51-100 |
101-110 |
111-129 |
≥130 |
|
|
Respiratory rate (bpm) |
<9 |
|
9-14 |
15-20 |
21-29 |
≥30 |
|
|
Temperature (C) |
<35 |
|
35-38.4 |
|
≥38.5 |
|
|
|
AVPU score |
|
|
Alert |
Reacting to voice |
Reacting to pain |
Unresponsive |
Table 1 Modified early warning score