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Jim Blair (Chapter 43)
Associate Professor (Hon)
Consultant Nurse Learning Disabilities
Great Ormond Street Hospital

Chris Brunker (Chapters 19, 20, 21 and 22)
Clinical Nurse Specialist
Neuro-Intensive Care
St George's University Hospitals NHS Foundation Trust

Claire Chinnock (Chapters 30, 31, 32 and 33)
Senior Lecturer Emergency Care
Kingston University and St George's,
University of London

Chris Hart (Chapters 39, 40 and 41)
Senior Lecturer Mental Health Nursing
Kingston University and St George's,
University of London

Caron Ireland (Chapters 44, 45, 46, 47, 48 and 49)
Paediatric Sister
Urgent and Emergency care
Sussex Community NHS Trust

Heather Jarman (Chapters 65 and 66)
Clinical Director for Major Trauma
Consultant Nurse in Emergency Care
St George's University Hospitals NHS Foundation Trust

Emma Menzies-Gow (Chapters 15, 16 and 17)
Senior Lecturer Cardiac Nursing
Kingston University and St George's,
University of London

Matthew Parkes (Chapters 51, 52 and 54)
Urgent Care Centre
St George's University Hospitals NHS Foundation Trust

Nicola Shopland (Chapters 50, 53 and 54)
Divisional Chief Nurse of Medicine
Surrey and Sussex Healthcare NHS Trust


Demand for emergency care has risen in the UK in recent years, calling for a reshaping of the system. Innovative models of service provision and the development of new roles in urgent and emergency care are two initiatives to ensure that care is delivered to the right people in the right place at the right time. While it is an exciting time to be working in this specialty, it is not a job for the fainthearted! Emergency nursing is a rewarding yet sometimes challenging career that demands a broad knowledge base and commitment to lifelong learning. 

This textbook offers up-to-date, peer-reviewed content that provides the reader with written and visual information relating to all aspects of emergency nursing. Chapters are organised into themes that reflect aspects of care or particular patient groups. Each chapter covers a clinical topic and includes background information, guidelines for assessment and care, and management of common clinical presentations. The text is accompanied by clear illustrations, photographs, diagrams and flow charts to further support learning. The ‘At a Glance' format is perfect for student nurses or nurses new to emergency nursing because it allows quick reference to the diversity that is emergency nursing.


We would like to thank the contributors for dedicating their time and expertise to assist the development of this textbook. We would also like to thank Rosie Maundrill and Darrel Manuel for allowing us to use their work for the acute kidney injury chapter.

Thanks also to Oscar Cavero and Nichola Brown for posing as models in the neuro chapters, and to Sarah Yeomans, Chloe Yeomans, Drew Yeomans and Isla Qureshi for posing as models in the paediatric chapters.

We are very grateful to the team at Wiley for their direction in keeping us on track. Finally, we would like to thank our families for their support and encouragement, not merely during the writing of this book, but throughout our careers.

Natalie Holbery
Paul Newcombe

About the companion website


Part 1
Initial patient assessment

  1. 1 The context of emergency nursing
  2. 2 Pre-hospital care
  3. 3 Triage
  4. 4 The ‘ABCDE’ approach
  5. 5 Track and trigger systems
  6. 6 Pain

The context of emergency nursing

Chart shows emergency nursing department nursing roles which include nurse consultant, educator, matron, emergency nurse practitioner and emergency nurse such as bands 5 to 7. Chart shows emergency department areas which include waiting room, triage such as public and ambulance entrances, resuscitation room, CT, UCC, CDU, pediatrics, majors and rest of the hospital.

The emergency department (ED) is a busy, fast-paced, unpredictable and often highly emotive place to work. ED nurses thrive on the pace, excitement and unpredictable nature of the environment. They need to be proficient in the assessment, recognition and care of patients across the lifespan with undiagnosed illness or injury. They are required to process large amounts of information to facilitate decision making, often in time-pressured situations. Violence and aggression towards ED staff has increased in recent years. Nurses therefore need to be adept at conflict resolution and proficient at communicating with all members of the public. Knowledge of legal and professional issues relating to consent, mental capacity, restraint, information sharing, forensics and end of life care is key to delivering safe and competent care. A number of core and advanced ED nursing roles exist in the UK (Figure 1.1) to ensure that care is delivered safely, efficiently and effectively.

Patients present to the ED day and night, every day of the year. They arrive at the ED in a number of ways (Chapter 2). Current health policy organises services to redirect people away from the ED whenever possible. In the UK, public education encourages individuals to choose the right option to meet their needs. The campaign advises people to access services beyond the ED such as a Pharmacist, a General Practitioner (GP) or a Walk in Centre (WIC) for non-emergency conditions. The majority of patients self-refer to the ED, however others may be referred by a telemedicine service (e.g. NHS 111), a GP, pharmacist or community nurse.

ED team

ED care is delivered by an inter-professional team of nurses, doctors and healthcare assistants. Current redesign of UK emergency and urgent care services has seen an increase in paramedics and physician associates working in EDs. Allied health professionals, such as speech and language therapists, physiotherapists, occupational therapists and dieticians, also work alongside ED nurses to address patients’ physical and social needs as required.

4-hour target

A drive to reduce waiting times and expedite care saw the introduction of the 4-hour target in the UK. That is, most patients are to be seen, treated and discharged within 4 hours of arrival. Approximately 25% of patients in the UK are admitted to hospital from the ED, with the remainder discharged to their usual place of residence. To support the delivery of care within 4 hours, medical and (in some places) surgical units have been established across the UK. These are separate to EDs and have developed as specialties in their own right.

Areas within the ED

EDs vary in size but all are structured to accommodate a variety of urgent and emergency presentations (Figure 1.2).


Triage is a nurse-led area and usually the first point of contact for patients. It is also known as the ‘front door’ of the hospital. Triage nurses determine the severity of the illness or injury and allocate priority accordingly. Triage is covered in more detail in Chapter 3.

Resuscitation area

The resuscitation area, or ‘resus’, is designed for critically ill and injured patients with high acuity on a triage scale. Examples include trauma, cardiac arrest, stroke, respiratory distress, sepsis and altered conscious levels. This area should be staffed by experienced, specially trained ED nurses with appropriate knowledge, skills and competence.


‘Majors’ tends to be the core of the ED and is usually the largest part of the department. It accommodates acutely unwell patients with a wide variety of conditions or complaints. Examples include surgical (appendicitis, bowel obstruction, pancreatitis), gynaecological and obstetric (ectopic pregnancy, miscarriage, per vaginal [PV] bleed), oncology (neutropenic sepsis, generally unwell), medical (pneumonia, headache), urology (urinary retention) and mental health presentations. It is usually staffed by core ED nurses. In some departments, emergency advanced nurse practitioners see, treat and discharge patients from majors.

Minors/Urgent care centre (UCC)

‘Minors’ is a term that has been traditionally used to describe patients with lower acuity who are seen in the ED. Recent restructuring of emergency care led to the development of UCCs, some of which are attached to an ED. Regardless of the term used, patients seen in this area of an ED are lower acuity with minor injuries or minor health problems. Examples include limb injuries, epistaxis, cellulitis, eye conditions, back pain, ear, nose and throat conditions, and simple wounds. Minors is usually staffed by core ED nurses, emergency nurse practitioners and doctors.


Children account for approximately 25% of emergency attendances. They and their families should have audio-visual separation from adult patients. This usually includes a separate triage area, waiting room and treatment area. Attention should also be paid to security and child-friendly facilities such as toilets, toys, and food and drink areas. A play specialist is recommended in departments that see more than 16,000 children a year. Registered children’s nurses should be available to care for unwell or injured children. Registered adult nurses will also come into contact with children and their families in areas such as triage, resus and, occasionally, urgent care.

Observation area/Clinical decision unit (CDU)

The introduction of the 4-hour target led to the establishment of areas within EDs aimed at providing holistic care beyond 4 hours. These areas usually consist of hospital beds with single-sex amenities, food and drink facilities, and dedicated treatment areas. Patients who require allied health assessment or social care input benefit from these areas. Care is often pathway led and may also include patients with low-risk conditions who are waiting for serial blood tests or other investigations.

Pre-hospital care

Diagrams show pre-hospital transport systems which include ambulance, car, bicycle and motorcycle. Diagram shows two cars collide with each other with scene assessments such as dispatch information, safety, hazards, parking, weather, access, injuries, illness, casualties, incidents, available resources and other services. Diagram shows a male body pointing care provisions which include airway management, psychological support, oxygen and nebulizers, cervical spine immobilisation, intravenous access fluids, drugs et cetera. Chart shows expansion of CASMEET which includes call sign, age of patient, sex of patient, mechanism of injury, examination carried out, estimated time of arrival and treatment given.

Depending on the local services provided, pre-hospital care is delivered by a range of individuals using a variety of vehicles (Figure 2.1). Overall, about 25% of patients attend an emergency department (ED) via ambulance. Emergency ambulances are usually staffed by two qualified paramedics who can provide a range of advanced life support treatments. However, one or more crew members may be a technician with a more limited skill set. Support or transport crews may have skills limited to just basic life support. Some ambulances use volunteer personnel who have widely differing skills.

Many ambulance services have single responders using cars, motorcycles or bicycles. These are usually paramedics, although nurses and doctors may also be employed. They are able to attend quickly, start emergency treatment and decide whether an ambulance or transfer to hospital is required.

Finally, helicopter emergency medical services provide rapid critical care to carefully selected patients in large urban or rural areas. These are staffed by highly trained medics and paramedics, and often respond to major trauma and critical illness. These teams may also use fast-response cars.

Pre-hospital environment

All patients attending the ED have come from one of a variety of pre-hospital environments. This may be their home, work, school, residential care facility or public place. The environment will dictate the approach required by pre-hospital personnel. Whatever the environment an assessment of the scene takes place first (Figure 2.2). Scene assessment begins after the dispatch operator has provided information that will indicate whether the problem is an injury or illness, for example.

On arrival, pre-hospital personnel need to determine the safety of the scene, any hazards or risks, access, number of casualties, nature of the illness, mechanism of injury and the need for extra help. They will need to rapidly assess for and declare a major incident if appropriate. They frequently work alongside other emergency service personnel (e.g. police, firefighters). ED staff should remember that working in the pre-hospital environment is very different from working within the comfort, safety and support of an ED.

Patient assessment

As with patient assessment in an ED, pre-hospital patient assessment is a dynamic process. Using a structured approach, pre-hospital personnel need to quickly distinguish critical (or time-critical) illness or injury from less urgent problems.


Accurate history taking is an essential part of patient assessment (Chapter 3). A patient may be alone or accompanied by friends, relatives, bystanders, colleagues, carers or healthcare professionals. There may be varying levels of background information available. The quality of this information will ultimately have an impact on the quality of the handover between pre-hospital and ED staff.

Physical assessment

Pre-hospital personnel use an ‘ABCDE’ approach to patient assessment (Chapter 4). Paramedics have advanced physical assessment skills similar to those of a doctor or nurse practitioner. They also have a range of skills and equipment (e.g. electrocardiogram) for measuring vital signs, blood sugar level, etc.

Psychological assessment

A significant minority of individuals requiring pre-hospital care do so because of mental health problems. Pre-hospital personnel need to determine the risk of the individual to themselves or others, and the severity of the current crisis (Chapters 39–41).

Care provision

Because pre-hospital personnel need to make autonomous decisions regarding care provision, they formulate a working diagnosis based on their assessment. They use this to inform a plan of action, which may include:


Depending on the scope of the practitioner, available resources and local protocols, a range of emergency interventions are provided using an ABCDE approach (Figure 2.3). Specific examples include the provision of cardiopulmonary resuscitation (CPR) during cardiac arrest and the management of emergency childbirth.

Transfer to ED

Conveyance of a patient to an ED or other service is guided by protocols and care pathways, for example:

  • Acute coronary syndrome (ACS)
  • Acute stroke
  • Major trauma.

Pre-hospital personnel triage the patient and determine whether a ‘pre-alert call’ is required to allow the ED to prepare for their arrival. The ‘CASMEET’ mnemonic is used to structure a pre-alert call (Figure 2.4). Blue-light transfer is used to minimise transfer time and patients are usually admitted directly to the resuscitation area. Most patients are not transferred to an ED by blue light.


Handover is a crucial point in the patient journey and requires good communication and documentation skills on the part of both groups of staff. Each ED has its own approach to receiving ambulances, but it should be carried out in a thorough and efficient manner. It should also be patient centred and protect patient dignity and privacy as far as possible. It is essential that all the relevant information is correctly received and recorded to ensure continuity and safety, and to maximise patient outcomes.


Flow chart shows MTS general discriminator which includes compromise, breathing, haemorrhage marked as red, abnormal pulse, hot baby, cold marked as orange, unconsciousness, moderate pain marked as yellow, mild pain, warmth marked as green which finally leads to blue. Table shows MTS triage categories which include immediate as red, very urgent as orange, urgent as yellow, standard as green and non-urgent as blue. Chart shows MTS stages of triage which include problem identification, gathering and analysing, evaluating and selecting, implementing and monitoring.

Triage is a system used to sort patients into categories based on priority. Priority is determined by a focused initial assessment that identifies specific criteria. The priority category indicates the time the patient is deemed safe to wait before being seen by an appropriate decision maker, usually an emergency department (ED) doctor or nurse practitioner.

Triage originates from the development of battlefield medicine during the Napoleonic war. The word ‘triage’ comes from the French verb ‘trier’, which means ‘to sort’. It was introduced into EDs in the 1980s, replacing what was essentially a ‘first come, first served’ system with ad hoc prioritisation.

Triage is the job of experienced, specially trained ED nurses. It is a high-risk activity and must be undertaken by those with the appropriate level of knowledge, skills and competence. Overestimating the severity of an illness or injury is less dangerous for patient care, but will have an impact on the smooth running of the ED. Underestimating the severity of illness or injury, and therefore creating a protracted waiting time, can have a significant impact on patient outcomes.

Manchester triage system (MTS)

MTS is the most commonly used triage system internationally. It is made up of the following components:

MTS uses a reductionist approach: all patients start as a Priority 1 (P1). Priory decreases as the user moves down the flow chart. Triage requires patient assessment skills in collecting both subjective and objective data. Figure 3.3 shows the stages required.

Problem identification

The nature of the presenting problem may or may not be immediately obvious. It may be clearly described by the patient, someone accompanying them or another healthcare professional. The problem may be non-specific initially, such as ‘unwell adult’, but may become more specific after the initial assessment, such as ‘diabetic emergency’.

Gathering and analysing

Subjective data (history taking)

Collecting an accurate focused history is the bedrock of effective triage. A funnelling process is used to encourage a patient to express the problem in their own words, but also to facilitate the efficient collection of relevant information. After greeting the patient, introducing themselves and gaining consent, the triage nurse should begin with an open question:

  • How can I help you today?
  • What is your reason for coming to hospital today?

Then a series of open and closed questions are used to clarify information and focus on areas that require further exploration:

  • Can you tell me more about that?
  • When did the problem begin?

Information gained will trigger a series of further questions or assessments. The MTS flow charts offer prompts for further questions to assess:

  • Pain
  • Chest pain
  • Urinary symptoms
  • Limb injury.

Finally, closed questions are used to ensure that all relevant information is collected:

  • Past medical history?
  • Any medications or allergies?

Objective data

Objective data are collected through patient observation. An ‘ABCDE’ approach should be used for unwell patients (Chapter 4). Observation should be used to corroborate the history:

  • Does the patient look well or unwell?
  • Are there any non-verbal signs of pain?
  • Are they walking on the injured limb?

Vital signs are not necessary for every triage decision unless local protocols dictate otherwise. Specific examination or investigations may be indicated:

  • Shortness of breath – peak expiratory flow rate
  • Limb injury – neurovascular assessment
  • Chest pain – electrocardiogram (ECG)
  • Vaginal bleeding – pregnancy test.

Evaluating and selecting

The information collected should now enable a triage decision to be made using the MTS flow charts or equivalent. Certain factors may create an automatic triage category due to local protocols, including:

  • Age (very young or very old)
  • Care pathways (e.g. fractured neck of femur).


The triage category should be clearly communicated to the patient and/or carer with an explanation of what it means and what will happen next. The triage decision should also be clearly documented including:

  • Presentation
  • Discriminator
  • Category.

The category is communicated to other ED staff to ensure that appropriate actions are taken. The triage nurse may also be able to offer treatment or care to the patient while they are waiting, including:

  • Analgesics (e.g. via a patient group direction [PGD])
  • A bed, trolley or private room
  • Dressings
  • Splints
  • Ice.

Some EDs may have a secondary assessment process in which more in-depth investigations are undertaken while the patient is waiting, including:

  • Blood tests
  • X-rays.


Triage is a dynamic process. The waiting room is a high-risk area and continuous monitoring is essential. If a patient’s condition changes, reassessment should be undertaken and the triage category adjusted accordingly. Furthermore, if the waiting time changes, this should be communicated to the patient.

The ‘ABCDE’ approach

Diagram shows a male body indicating causes of acute deterioration which includes airway, breathing, circulation, disability and exposure. Image described by caption. Assessment chart shows ABCDE approaches which includes Airway; talking, swelling, Breathing; drowsy, injuries, Circulation; pale, cool, Disability; GCS, drugs and Exposure; wounds, rashes et cetera. Management chart shows ABCDE approaches which includes airway; intubation, suction, breathing; nebulisers, circulation; IV access, blood tests, disability; positioning, IV glucose and exposure; prevent heat loss et cetera.

Most patients presenting to the emergency department (ED) are not critically ill or acutely deteriorating. However, many are. These patients need early identification, rapid assessment, appropriate initial management and establishment of a definitive plan.

Figure 4.1 shows common causes of acute deterioration. Factors that increase risk include:

Patients who experience cardiac arrest often show signs of deterioration before the event (Figure 4.2). Those identified and treated early tend to have better outcomes, and cardiac arrest may be prevented. Early warning systems assist in identification and guiding appropriate actions (Chapter 5).

Using the ABCDE approach

Many systems of patient assessment exist. However, the ABCDE approach is recommended for the assessment (Figure 4.3) and management (Figure 4.4) of the deteriorating patient. It is an easy-to-remember mnemonic (Airway, Breathing, Circulation, Disability, Exposure), providing a standardised and efficient approach that can be used in all contexts. It allows the ED nurse to identify problems in order of priority (i.e. those that pose immediate threats to life). Problems should be addressed with simple interventions as they are identified. Constant reassessment to monitor progress is key. The ABCDE approach can be undertaken by an individual (as a linear, vertical approach) or as a team (as a simultaneous, horizontal approach), for example in cases of trauma or cardiac arrest. However, if alone, the ED nurse should have a low threshold for calling for help as soon as significant signs become apparent.


Airway obstruction is a medical emergency. Untreated, it leads to hypoxia, organ damage, respiratory or cardiac arrest and eventually death. A combination of lowered consciousness, vomiting and supine positioning is a common triad in critical illness and will quickly compromise airway patency. C-spine injury should always be suspected in trauma patients and considered during airway management (Chapter 7).

Basic airway assessment is performed by talking to the patient and seeking a verbal response. The patient who is talking can be assumed to have a patent airway. If the patient is not talking, then the presence of breathing should be quickly confirmed. In the absence of breathing, the advanced life support (ALS) algorithm should be followed (Chapter 18). Further airway assessment may reveal visible or audible signs of obstruction.

Most airway problems can be resolved with simple interventions such as basic airway manoeuvres (head-tilt/chin-lift/jaw-thrust), suctioning, insertion of simple airway adjuncts (oropharyngeal or nasopharyngeal airways) and positioning (lateral). Patients with a reduced level of consciousness (Glasgow Coma Scale [GCS] <8) or those requiring ongoing airway support (e.g. toleration of an oropharyngeal airway) require definitive airway management. Call an anaesthetist and prepare for intubation.


There are many causes of acute breathing problems. Again, left untreated, these will lead to hypoxic organ damage etc. Listening to what the patient is saying is essential. Are they complaining of dyspnoea? Are they talking in full sentences? Vital signs include respiratory rate and pulse oximetry. Pulse oximetry will indicate oxygen levels, but not carbon dioxide levels. Arterial blood gas (ABG) analysis is required to determine this. RIPPAS is a useful mnemonic for structuring respiratory assessment (Chapter 8). A chest X-ray is often indicated.

All critically ill patients require high concentration oxygen via a non-rebreathe mask at 10–15L/min. Those at risk of CO2 retention (i.e. with chronic obstructive pulmonary disease [COPD]) should start at 28% via a venturi mask (Chapter 9). Depending on their condition, the patient may benefit from being sat upright to aid chest expansion. Specific respiratory interventions may be indicated, such as nebulisers, non-invasive ventilation, needle decompression and chest drain (Chapters 10, 17, 58). When there is absent or ineffective breathing, or if intubation has taken place, artificial ventilation will be required.


Problems with circulation commonly arise from disruption to the circulating volume (shock) or because of a primary cardiac cause (acute coronary syndrome [ACS], arrhythmia). Poor perfusion will quickly lead to hypoxic organ failure and death.

Monitoring equipment should be used appropriately, but it is also important to touch the patient to palpate the quality of the pulse and feel the warmth of the skin (Chapter 12). Assessment focuses on looking for compensated shock (normal blood pressure [BP]) or decompensated shock (low BP) (Chapter 13). The presence of bleeding should also be identified. A 12-lead electrocardiogram (ECG) may be indicated (Chapter 14).

Management includes siting at least one large bore intravenous (IV) cannula. Draw blood for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching if required. Unless there is an obvious cardiac cause, give a rapid fluid challenge and reassess. Repeat if necessary and monitor for response and tolerance. Pressure should be applied to external bleeding (Chapter 12). Specific interventions may also be indicated.


Level of consciousness is usually determined early during assessment and constant monitoring is essential. The AVPU (Alert, Voice, Pain, Unresponsive) scale or GCS should be used and pupillary reaction assessed (Chapter 19). Consideration of recent drugs or medications may also provide clues. Blood sugar level must be measured and hypoglycaemia treated urgently with IV glucose. Hyperglycaemia may also be found (Chapter 28). CT scanning and urgent referral may be indicated (Chapter 20).


Full exposure is essential to reveal any other obvious abnormal signs. Again, specific interventions may be indicated. Temperature should be measured to identify hypothermia or systemic infection. Cover the patient to avoid heat loss and protect dignity.

Ongoing management

Constant reassessment is essential. Findings should be clearly documented and communicated using a structured approach (ABCDE, National Early Warning Score [NEWS], SBAR [Situation, Background, Assessment, Recommendation, see Chapter 5]). Urgent referral should take place, ensuring that an appropriate definitive plan is established.

Track and trigger systems

NEWS table shows respiration rate, oxygen saturations, supplemental oxygen, temperature, systolic BP, heart rate and level of consciousness. NEWS chart shows respiration rate, temperature, blood pressure, heart rate, blood sugar et cetera. It also tabulates name, DOB, date and time. NEWS triggers chart shows news score for 0, 1 to 4, 5 or more and 7 or more conditions with frequency of monitoring and clinical response.

Track and trigger’ systems, such as early warning scores (EWS), are advocated in the care of patients who present with acute illness or who are at risk of deterioration. A number of reports have highlighted the importance of these systems in identifying and successfully responding to these high-risk patient groups. Physiological track and trigger systems rely on periodic observation and recording of selected physiological signs (track) with clearly defined action criteria (trigger). Action typically results in increased frequency of monitoring and escalation of care.

EWS can help in determining appropriate allocation to clinical areas of the emergency department (ED) and triaging; assist in referral to specialist medical teams; support decision making for allocation to high dependency unit (HDU) or intensive care unit (ICU) beds; and provide evidence of patients who are unsafe to be transferred or who have been allocated to an inappropriate ward.

National Early Warning Score (NEWS)

Historically, within the UK, there were a number of track and trigger systems being used. Although they shared core principles, there was a lack of standardisation between them. The potential for misuse and misinterpretation when patients and staff moved between clinical areas defeated the object of a system that was designed to reduce risk. As a result, the Royal College of Physicians developed NEWS.

Using NEWS

NEWS (Figure 5.1) is a simple system in which a score is allocated to six standard physiological measurements commonly undertaken during patient assessment and monitoring in the ED:

  • Respiratory rate
  • Oxygen saturations
  • Temperature
  • Systolic blood pressure
  • Pulse rate
  • Level of consciousness.

Observations are recorded on the standardised NEWS chart (Figure 5.2). For each physiological parameter, a normal ‘healthy’ range is defined. Measured values outside this range are allocated a score that is weighted and colour-coded on the observation chart. The size of the score indicates how extreme the parameter varies from normal, and reflects the severity of the physiological disturbance. The individual scores are then added together. If supplemental oxygen is required to maintain oxygen saturations, two additional points are added to the total. The total score indicates the level of clinical risk, which is also colour-coded (Figure 5.3). A score of 0–4 indicates low risk (green), 5–6 medium risk (orange) and 7 or more high risk (red). A score of 3 in any individual parameter also indicates medium risk.

Low risk

Patients with a score of 0 should continue to have routine NEWS monitoring with every set of observations (minimum 12-hourly). A score of 1–4 requires a registered nurse to assess the patient (when other healthcare staff are involved in recording observations). The ED nurse must then decide if increased frequency of monitoring and/or escalation of clinical care is required. Junior staff should seek support with decision making if necessary. Frequency of observations should be a minimum of 4–6-hourly. ED patients will often have hourly observations undertaken anyway, but the 4–6-hourly frequency may be relevant in the clinical decision unit (CDU), or similar, where patient stay is longer.

Medium risk

A medium risk score (total of 5–6 or 3 in one parameter) requires the ED nurse to urgently inform the doctor or medical team caring for the patient. Urgent assessment by a clinician with core competencies to assess acutely ill patients is required. Additionally, clinical care should be provided in an environment with monitoring facilities. This may require the patient to be moved to a monitored cubicle in the major illness or resuscitation area of the ED. Frequency of observation should be increased to a minimum of 1-hourly if not already.

High risk

Patients with a score of 7 or more are considered those at greatest risk of deterioration. The ED nurse should immediately inform the doctor or medical team caring for the patient – this should be at least at specialist registrar level. Emergency assessment should be undertaken by a clinical team with critical care competencies that also includes a practitioner with advanced airway skills. All middle-grade and consultant ED medical staff should be able to provide this level of care, but other senior medical/ICU/anaesthetic staff may be called on. The patient should be considered for transfer to a level 2 or 3 care facility (i.e. higher dependency or ICU). They should be moved to the resuscitation area immediately, if not there already, in the interim. High-risk patients may include those in peri-arrest, and therefore activating a cardiac arrest call may be indicated depending on local protocols (Chapter 18). Some ED patients may have a high NEWS score, but an appropriate treatment plan and/or referral to HDU or ICU may already be in place to meet their needs.

SBAR (Situation, Background, Assessment, Recommendation)

Alongside track and trigger systems, a shared communication tool, such as SBAR, should be employed when seeking help with a deteriorating patient. The benefits of SBAR are that it is standardised, concise and easy to remember. Its key components include:


  • Identify yourself and the site or unit you are calling from
  • Identify the patient by name and the reason for your report
  • Briefly describe your concern.


  • Give the patient’s reason for admission
  • Explain significant medical history
  • Briefly describe relevant recent events.


  • Provide key vital signs
  • Use ABCDE and NEWS
  • Suggest your clinical impression.


  • Explain what you need
  • Be specific about request and time frame
  • Make suggestions
  • Clarify expectations.