Sneak peek: Alternative EWS step for unmeasured values

The Early Warning Score (EWS) helps identify a patient’s deteriorating condition, which may even save the patient’s life. What if, however, the patient refuses to be tested or some of their values cannot be measured for some reason?

Monitoring the patient’s condition even in challenging situations

The patient’s deteriorating condition may not be detected if the EWS cannot be completed. The solution to the problem is to record the unmeasured values as such. For the physiological measurement value, record: unable to measure/patient refuses. The nurse should also assess whether the unmeasured value raises concerns about the patient’s condition. If the nurse is unable to measure a certain value and believes it may be outside the reference values, the score for the unmeasured value is 3 (

In this way, the EWS can be calculated even in challenging situations and the patient’s condition continues to be monitored systematically. In addition, the reason for not measuring the value is documented in the electronic health record.

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