NCEC National Clinical Guidelines - INEWS/PEWS/EMEWS/MEWS

The National Clinical Effectiveness Committee (NCEC) oversees the National Clinical Guidelines for:

Irish National Early Warning System (INEWS)

What's new in INEWS V2

increased emphasis on clinical judgment and using the INEWS track and trigger tool as an aid to assist clinical judgment and decision-making rather than as a standalone tool.
the addition of ‘healthcare worker/patient/family concern’ on the INEWS patient observation chart to capture, acknowledge and act on early concern.
new ‘cues for caution’ included on the INEWS Escalation and Response Protocol to remind staff to think about the potential for patient deterioration.
an increased emphasis on changes in respiratory rate as a key early indicator of deterioration.
‘New confusion’ - an early sign of deterioration - is captured as ‘C’ in ACVPU.
the requirement for a minimum of 6 hourly observations for the first 24 hours following admission.
A new recommendation stating that the adjustment of INEWS parameters or a patient’s INEWS score is NOT permitted.
the option for a Consultant or Registrar to use a modified INEWS escalation and response protocol for patient’s whose baselines fall outside of INEWS parameter ranges.
the facility for a Registered General Nurse to defer escalation for a brief period of time (max 30 minutes).
A three-tiered response model (bedside, urgent and emergency) evolving to an Advanced Nurse Practitioner response service.
closed-loop governance to drive improvement at clinical and organisational levels

INEWS patient observation chart

The national INEWS patient observation chart was redesigned to correspond with the revised clinical guideline. Human factors expertise was sought to ensure optimal chart design as were the views and experiences of frontline staff. Two sections were added to the back of the chart – one for Consultant or Registrar documentation of a Modified Escalation and Response Protocol and the second for the documentation by an RGN of the decision to defer escalation.

The Glasgow Coma Scale (GCS) is now included in the three-fold version of the chart. The chart is also available as a two-fold design without the GCS.

INEWS education resources

INEWS education resource

The INEWS V2 education programme aims to support clinical staff in the acute settings to use the Irish National Early Warning System to anticipate, recognise, escalate, respond and evaluate a non-pregnant patient (16 years and older) effectively in line with the INEWS V2 National Clinical Guideline.

INEWS V2 education resources:

Irish Early Maternity Warning System (IMEWS)

IMEWS is a nationally agreed system developed for early detection of life-threatening illness in pregnancy and the postnatal period.

IMEWS should be used for women who are clinically pregnant or who were delivered within the previous 42 days. An e-learning education programme was published in tandem and is available on HSELanD.

IMEWS should be used to complement clinical care and it is not designed to replace clinical judgement. Clinical concern about an individual woman should trigger a call to medical staff irrespective of the IMEWS.

IMEWS National Clinical Guideline (gov.ie)

Emergency Medicine Early Warning System (EMEWS)

EMEWS national clinical guideline was developed by the HSE National Clinical Programme for Emergency Medicine and was launched in 2018 by the Minister for Health.

It applies to adult patients (16 years and older) attending an Emergency Department (ED) in Ireland and is relevant to all healthcare professionals working in EDs.

EMEWS was developed in response to growing concern and evidence raised by HIQA in 2012. They found that patients were deteriorating in overcrowded EDs in the time between triage and clinician assessment. The guideline recognises the complexity and dynamic nature of the ED.

Digital EMEWS

Digital EMEWS has been piloted in two sites and has been found to be an easy to use digital tool.

Digital EMEWS enhances the:

visibility of the deteriorating patient
promotes earlier intervention and efficient management

This has led to a recommendation for national rollout of Digital EMEWS.

This guideline should be used in conjunction with other National Clinical Effectiveness Committee national clinical guidelines.

Paediatric Early Warning Score (PEWS)

Making hospitals safer for children

The Paediatric Early Warning System (PEWS) provides a framework for care and empowers clinicians to act on behalf of a child with signs of deterioration or about whom they have clinical concerns.

It is designed to make hospital admissions safer for children and help staff care for deteriorating paediatric patients.

A National Clinical Guideline on the Irish Paediatric Early Warning System (PEWS) was published by the National Clinical Effectiveness Committee and Department of Health in November 2015 and updated in November 2016.

Access the PEWS National Clinical Guideline (gov.ie)

Since this publication the International Sepsis Guidelines for Children Implementation Plan 2021 and Paediatric Sepsis Form has been developed by the HSE National Clinical Programme for Sepsis.

Paediatric sepsis form (PDF, 175 KB, 1 Page)

International sepsis guidelines for children implementation plan

Designed to be used in all hospitals

PEWS is designed to be used in tertiary, regional and peripheral hospital settings.

It takes a multifaeted approach to improving clinical outcomes using safety interventions such as:

national paediatric observation charts incorporating the PEWS scoring tool
escalation guide
standardised communication (ISBAR)
timely medical and nursing input
clear documentation of management plans
ongoing reassessment of the child

Resources for training and support

These resources replace all earlier editions and are correct from June 2023 when changes were made to align these resources with new Sepsis Guidelines for Children

Implementation toolkit

This toolkit contains the resources required by PEWS Governance Committees and senior management teams considering the implementation of PEWS.

The PEWS National Clinical Guideline provides the framework for implementation and should be referred to for guidance.

Training toolkit

This toolkit contains the resources required by the PEWS leads, Trainers and Champions to facilitate training for implementation and ongoing retraining/updates.

You must refer to the PEWS National Clinical Guideline and the specific guidance for implementation and training when accessing and using these services.

Audit toolkit

The resources in this toolkit are to aid PEWS Governance bodies, leads, trainers and champions to undertake audit of process and outcome measures, as required by the PEWS National Clinical Guideline (gov.ie).

These resources are also required by the HSE BIU KPIs suite requirements.

Parent and carer engagement toolkit

We recognise that parents and carers know their children best and can be acutely aware that their child is unwell or ‘just not right’, sometimes before the physiological parameters become abnormal.

The concerns of parents, families and caregivers are a core scoring parameter in PEWS. An assessment of parent or carer concern is undertaken at every observation opportunity. Concern on the part of a parent or carer should merit appropriate consideration and may require escalation.

The resources in this toolkit will assist the bedside clinician in supporting parents to participate in the concern assessment and to aid parents in expressing their concern about their child.

These resources were adapted with kind permission from Birmingham Children’s Hospital Listening to up communication bundle. We are grateful for their support of this project.

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