Aid to identifying clinical deterioration: The Veterinary Early Warning Score

This is article thirty-two in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

After morning rounds Sam, a student veterinary nurse, begins working their way round the ward giving their patients their morning treatments. Sam’s first patient is Barley, a lovely 5-year-old cocker spaniel who is recovering after enterotomy surgery two days ago to remove a corn on the cob that had become a foreign body. Over the past few days Barley has been recovering well and returning to the affectionate, playful, waggy tailed dog that his owners love. This morning Barley is quiet; he doesn’t greet them as he normally would and is uninterested in his breakfast, curled up in the corner of his kennel. Sam is worried that Barley is deteriorating. Having been introduced to Early Warning Scoring sheets at university, they grab the one stuck to the wall near Barley’s kennel and begin a thorough assessment.

Early identification of deterioration and rapid intervention of care is a common theme throughout human centred medicine with initiatives demonstrated in paediatrics, maternity, mental health, and critical care. Multiple-parameter or aggregated weighted, early identification care scoring systems are used to alert the medical team to patients who are most at risk from deterioration. Scoring systems (such as the National Early Warning Score system (NEWS)¹ trigger the implementation of fast and direct care to prevent worsening of the patient's condition whilst also preventing serious adverse events² and reducing the requirement for more invasive care.

Early warning score systems are a way of summarising a patient's progress in real time - they create an easily understood patient score, which means health can be measured, recorded and tracked, triggering interventions as required. Utilising physiological parameters commonly recorded such as respiratory rate, oxygen saturation, consciousness and temperature, each parameter is scored 0-3 with clinical responses provided for the total score. For a score of 0, the patient remains on a routine level of monitoring, whilst a low score, of 1- 4, can result in the nurse increasing the frequency of monitoring or implementing greater clinical care. A low to medium score whereby a 3 is scored in any single parameter, triggers an assessment by a doctor who can also increase the frequency of monitoring or request a change in clinical care. If the patient scores 5-6, classed as medium, an urgent review by a doctor is required or care may be escalated to a critical care team. Finally, a high-risk score of 7 or greater, results in emergency assessment of the patient by the critical care team and in some cases, a transfer to a high dependency unit¹.

While human centred nursing tools provide insights, not all evidence within this field is applicable. For example, the commonly recorded parameters and care triggered at each assessment will vary between species, practice resources, patient signalment, character, condition, and the owner’s wishes. Therefore, a veterinary specific identification system was created.

The Veterinary Early Warning Score (VEWS)

An alert system is particularly important considering the current workforce crisis³, whereby veterinary teams are stretched, and oversights can occur. It is particularly beneficial for student veterinary surgeons and nurses, who are learning normal parameters, providing them with a prompt to seek a review by a qualified member of the team and empowering them to speak up when they believe there is reason to do so. The combination of objective and subjective assessments aims to harness the veterinary surgeons or nurses experience and instincts, whilst balancing them with the patients’ clinical signs. This combination is particularly important in veterinary patients who often mask signs of illness and have alternate methods of communication which are not always detected.

As with human centred care, VEWS is to be used for non-sedated patients to identify those in the early stages of deterioration, requiring intervention.

Kirby’s rule of 20, lists twenty parameters which should be checked daily for patients within an emergency or critical care setting to create differential diagnoses and treatment plans⁴.

VEWS incorporates seven core parameters based on Kirby's⁴ rule of 20:

• Respiratory rate
• Respiratory effort
• Pulse rate
• Pulse quality
• Temperature
• Mentation
• Demeanour

With a further three parameters to be recorded for patients on additional monitoring as stipulated by the veterinary surgeon:

• Systolic blood pressure
• Urine output
• Oxygen saturation

The parameter ranges within VEWS were created utilising the averages recorded in the veterinary practice and allocated green, amber or red. VEWS suggests that one amber score requires the implementation of 30-minute observations and that one red, or two amber scores requires a clinician to be contacted immediately.

However, a set list of interventions following the assessment can also be left to be organised locally and, on a patient-by-patient basis, with additional space left for documentation of this within the chart.

Sam worked their way through the VEWS scoring sheet: Barley’s respiratory rate and effort were both normal – green scores were given for both. His pulse was a little elevated – 130bpm and therefore scored amber and his temperature was recorded at 39.1^oC – a red score, as he was dull and lethargic his mentation scored amber, and his demeanour was also scored amber. Sam counted the amber scores; three and one red score. This confirmed their concerns and they felt confident finding the vet in charge of Barley's care, reporting the score, and asking for further advice.

Download the VEWS scoring sheet here - PDF.

Download the VEWS scoring sheet here - Word.

Adam, Barley’s vet, listened attentively to Sam and agreed “Sounds like somethings going on, I will come and see him now”. Adam examined Barley thoroughly, performing an AFAST scan in his kennel to rule out the presence of free fluid in his abdomen and then turned his attention to Barley’s kennel sheet. Barley had been so comfortable yesterday that he had pain scored zero or one throughout the day so had had no methadone “I wonder if his bounciness has resulted in him being a bit sore this morning, Sam, can we try 0.2mg/kg methadone IV and please can you pain score him and VEWS score him again in 30 mins and let me know what you find? Please can you also add pain scoring every 4 hours to his kennel sheet, looks like we forgot to transfer it across from yesterday's sheet. His current pain score is 10.”

VEWS is currently being used in a range of veterinary practices and has received positive feedback from those using it. Ensuring that small changes in a patient's condition are identified and actioned as soon as possible, to ensure the best patient outcomes, this document helps me to do this.

Sam gave Barley the methadone as requested and kept a close eye on him. When 30 minutes had passed, they performed a pain score and VEWS score. Barley’s respiratory rate and effort, temperature and pulse rate were all normal – scoring green. Whilst he was still a little lethargic (scored amber) he wagged his tail when they went into his kennel, so his demeanour scored green too. “Just one amber score this time, so much better,” Sam thought. They checked the instructions, which said to score again in 30 minutes. They called Adam, who sounded relieved “That’s great, please can you do as VEWS suggests and rescore him every 30 minutes and let me know of any changes?”

Sam was so glad that they had performed the VEWS score on Barley, and he was comfortable again now, for a moment they were worried that he was developing sepsis. Sam was also glad they had been encouraged to implement the VEWS scoring tool, and that they worked in a practice that was so proactive when it came to quality improvement. Sam mused “Next job was to think about how they could implement a system that would help them make sure pain scoring was always done on all inpatients”.

About the Veterinary Early Warning Score

The early warning system presented in this feature, VEWS, was created following a similar care sheet being implemented during the author's maternity care. The author identified the benefits of this system and wished to implement them in their veterinary nursing practice. 

The recommendations provided were first defined through practice protocols and then reviewed and amended following the implementation of VEWS as part of an initial trial in a multidisciplinary referral hospital. A further ten veterinary establishments then expanded the trial, providing a peer review and additional adaptations, prior to its release to 500 practices.

The parameter ranges within VEWS were created utilising the averages recorded in the veterinary practice. These were then peer-reviewed by 15 veterinary professionals of varying qualifications and positions, including veterinary surgeons (general practice and ECC and anaesthesia specialist vets) and veterinary nurses. Now that the pilot phase is over, research is required to ensure that multiparameter score systems and VEWS in particular, prevents the deterioration of patients through early intervention, in addition to validating the parameters provided and the suggested protocols. This research should focus on patient outcomes and hospital stays to ensure that the tool is aiding the veterinary team to identify at-risk patients and implementing the correct care. 

Checklist - what you can do next

• Evidence-based veterinary medicine combines clinical expertise with the most relevant and best available scientific evidence. To find out more and how you can incorporate evidence-based veterinary medicine into your daily practice, access 4 hours of free CPD with the EBVM for Practitioners course.
• Our free to access QI Boxset is available in bite sized episodes to help you learn about Quality Improvement in a way that suits you best. Series 4: Guidelines covers how to appraise and use the evidence to structure guidelines to to fit your practice circumstances.  Series 5: Using QI tools for patient safety - Checklists and more covers the attributes that make evidence-based checklists effective in helping us communicate effectively as a team to deliver safe, quality care. 
• Read our QI Feature 'Delivering consistent quality care: Care plans, care bundles and integrated care pathways' to discover the benefits of planning and executing evidence-based interventions together for improved patient outcomes.
• Subscribe to inFOCUS to be kept up to date with the latest research papers, critically appraised topics, and more, that have the potential to positively impact patient care. inFOCUS is RCVS Knowledge's editorially independent veterinary journal watch where articles are assessed by the Clinical Review Team who score them for relevance, quality, and interest to the veterinary practitioner. The top-scoring articles are summarised with helpful commentary to assist those based in practice to help improve the quality of care delivered.

References

1. National Early Warning Score systems that alert to deteriorating adult patients in hospital (2020) [NICE] [online].  Available from: https://www.nice.org.uk/advice/mib205 [Accessed 5 November 2023]
2. Kyriacos, U., Jelsma, J. and Jordan, S. (2011) Monitoring vital signs using early warning scoring systems: a review of the literature. Journal of Nursing Management, 19 (3), pp. 331-330. https://doi.org/10.1111/j.1365-2834.2011.01246.x
3. RCVS (2022) RCVS workforce action plan [RCVS] [online]. Available from: https://www.rcvs.org.uk/news-and-views/publications/rcvs-workforce-action-plan/ [Accessed 5 November 2023]
4. Kirby, R. (2016) An introduction to SIRS and the Rule of 20. In: Kirby, R. and Linklater, A. (eds.) Monitoring and intervention for the critically ill small animal: The Rule of 20. Oxford: John Wiley & Sons. pp. 1-8

Authors

Belinda Andrews-Jones VTS (ECC) Dip AVN (Surg) CMgr RVN PG Dip Vet Ed MInstLM FCMI FHEA  

Belinda has been working within the veterinary profession for over thirty-two years. She has vast experience within ECC nursing, management and teaching.

Belinda is currently the Chair of the RCVS VN council. Previously Belinda was employed at the Royal Veterinary College (RVC), for 16 years as Senior Nurse for the Emergency and Critical Care (ECC) department and also a clinical educator. Here she taught undergraduate and post graduate veterinary surgeons and veterinary nurses in ECC. While at RVC she became the first nurse in England to gain the prestigious (USA) Veterinary Technician Specialist qualification in ECC. She was previously the first Director of Nursing for a commercial veterinary company in the world. In 2022 Belinda was awarded the International Dr Earl Rippie Scholarship for Veterinary Nursing Leadership.

Sarah Batt-Williams MSc Vet Ed. FHEA Bsc (Hons) RVN

Sarah is a Senior Teaching Fellow and the Course Director of undergraduate veterinary nursing at the Royal Veterinary College (RVC), having previously worked as a lecturer at Middlesex University and the College of Animal Welfare (CAW). Prior to a move into education, Sarah worked as an RVN and senior RVN in a range of first opinion, private referral, university referral and emergency settings, in the UK and Australia. Sarah has also volunteered in the USA and South Africa, with both domesticated animals and wildlife. Sarah has a master's in veterinary education, completing her thesis on the preparedness of veterinary nursing and veterinary students for reflection, now a requirement of CPD. 

RCVS Knowledge Contributor

Helen Silver-MacMahon MSc (Dist) PSCHF Cert VNECC DipAVN(surg) Cert SAN RVN

Helen is a Quality Improvement Clinical Lead at RCVS Knowledge. Helen qualified as an RVN in 2000 and has worked in both first opinion and referral hospitals. Since qualifying, she has gained certificates in ECC and Small Animal Nutrition and the Advanced Diploma in Veterinary Nursing (Surgical).

In 2021, Helen completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh and is currently undertaking a PhD at the University of Lincoln exploring the non-technical skills that veterinary nurses require when monitoring and maintaining anaesthesia. She is also collaborating with the University of Aberdeen to research Incivility in veterinary practice and working towards chartered ergonomist status.

Helen is an RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust.

Helen is passionate about developing the veterinary profession's understanding of Human Factors as a powerful aid in improving patient safety, enhancing performance, and supporting the wellbeing of the veterinary team. She enjoys designing bespoke coaching, training and speaking on topics that advance the quality of care. She has written articles and co-authored several book chapters on both clinical and of non-clinical aspects practice.

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